European Journal of Cardio-Thoracic Surgery Advance Access published April 17, 2014
ORIGINAL ARTICLE
European Journal of Cardio-Thoracic Surgery (2014) 1–7 doi:10.1093/ejcts/ezu167
David R. Koolbergena,b,‡*, Johan S. J. Manshandena,‡, Berto J. Boumac, Nico A. Blomd, Barbara J. M. Mulderc, Bas A. J. M. de Mola and Mark G. Hazekampa,b a b c d
Department of Cardiothoracic Surgery, Academic Medical Center, Amsterdam, Netherlands Department of Paediatric Cardiology, Leiden University Medical Center, Leiden, Netherlands Department of Cardiology, Academic Medical Center, Amsterdam, Netherlands Department of Paediatric Cardiology, Academic Medical Center, Amsterdam, Netherlands
* Corresponding author. Department of Cardiothoracic Surgery, Academic Medical Center Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands. Tel: +31-20-5669111; fax: +31-20-6962289; e-mail: [email protected] (D.R. Koolbergen). Received 14 October 2013; received in revised form 28 February 2014; accepted 7 March 2014
Abstract OBJECTIVES: To evaluate our results of valve-sparing aortic root replacement and associated (multiple) valve repair. METHODS: From September 2003 to September 2013, 97 patients had valve-sparing aortic root replacement procedures. Patient records and preoperative, postoperative and recent echocardiograms were reviewed. Median age was 40.3 (range: 13.4–68.6) years and 67 (69.1%) were male. Seven (7.2%) patients were younger than 18 years, the youngest being 13.4 years. Fifty-four (55.7%) had Marfan syndrome, 2 (2.1%) other fibrous tissue diseases, 15 (15.5%) bicuspid aortic valve and 3 (3.1%) had earlier Fallot repair. The reimplantation technique was used in all, with a straight vascular prosthesis in 11 (26–34 mm) and the Valsalva prosthesis in 86 (26–32 mm). Concomitant aortic valve repair was performed in 43 (44.3%), mitral valve repair in 10 (10.3%), tricuspid valve repair in 5 (5.2%) and aortic arch replacement in 3 (3.1%). RESULTS: Mean follow-up was 4.2 ± 2.4 years. Follow-up was complete in all. One 14-year old patient died 1.3 years post-surgery presumably of ventricular arrhythmia. One patient underwent reoperation for aneurysm of the proximal right coronary artery after 4.9 years and 4 patients required aortic valve replacement, 3 of which because of endocarditis after 0.1, 0.8 and 1.3 years and 1 because of cusp prolapse after 3.8 years. No thrombo-embolic complications occurred. Mortality, root reoperation and aortic regurgitation were absent in 88.0 ± 0.5% at 5-year follow-up. CONCLUSIONS: Results of valve-sparing root replacement are good, even in association with a high incidence of concomitant valve repair. Valve-sparing aortic root replacement can be performed at a very young age as long as an adult size prosthesis can be implanted. Keywords: Aortic valve repair • Aortic valve preservation • Valve-sparing root replacement
INTRODUCTION Long-term results of valve-sparing root replacement (VSRR) are very encouraging, both in degenerative aneurysm disease [1, 2] as well as in connective tissue disorder [3, 4]. Consequently, indications and applications are expanding [5–7] and the valve-sparing operation is incorporated more and more into the routine practice of the general and congenital cardiac surgeon. Nonetheless, different surgeons are still searching for further improvements to optimize the valve-sparing aortic root replacement technique [8, 9]. In our centre for congenital heart disease Amsterdam–Leiden (CAHAL), we are gaining experience in performing elective valvesparing operations for treatment of aortic root aneurysm in adults and adolescents with connective tissue disorders, valve pathology and congenital heart defects. In this series, a high number of concomitant valve repairs and other surgical procedures were performed. With the use of the Valsalva graft (Gelweave Valsalva™ by † Presented at the 27th Annual Meeting of the European Association for CardioThoracic Surgery, Vienna, Austria, 5–9 October 2013. ‡ The first two authors contributed equally to this work.
Sultzer Vascutek, Renfrewshire, Scotland) a fast and reproducible technique was developed in order to keep cross-clamp and bypass times within safe limits for multiple procedure cardiac surgery. An efficient modification of sub-commissural annuloplasty is presented that we used in patients in whom aortic annulus reduction was required. With this study our short to mid-term results are evaluated.
PATIENTS AND METHODS Study design Aortic valve-sparing operations were performed in a total number of 97 adolescent and adult patients (mean age 38.4 ± 12.8 years; range: 13.4–68.6 years; minimal body weight ≥50 kg) with congenital heart disease at the Academic Medical Centre in Amsterdam and Leiden University Medical Center from September 2003 to September 2013. All patients had aortic valve-sparing root replacement by means of reimplantation of the aortic valve into a vascular
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
CONGENITAL
Valve-sparing aortic root replacement†
2
D.R. Koolbergen et al. / European Journal of Cardio-Thoracic Surgery
prosthesis. Two surgeons at two locations performed the surgery. A retrospective study was performed analysing patient records and preoperative, postoperative and recent echocardiograms.
Patient characteristics Patient characteristics and preoperative clinical profile are listed in Table 1. Clinical diagnoses were Marfan syndrome in 54 (55.7%), Loeys–Dietz in 2 (2.2%) and bicuspid aortic valve in 15 (15.5%). Three patients received VSRR late after tetralogy of Fallot correction; one after a previous Yacoub procedure; another one late after a Ross procedure and five after repair of aortic coarctation in childhood. Preoperative aortic root diameter was 49.5 ± 4.9 mm and mean preoperative annular diameter was 27.1 ± 3.0 mm. Preoperative left ventricular ejection fraction (LVEF) was >50% in 90 (92.8%), 30–50% in 7 (7.2%) and 30 Smoking Diabetes Hypertension High cholesterol Chronic obstructive lung disease EuroSCORE (r) ± SD Previous surgery: Total Fallot correction Ross procedure Aortic coarctationa VSRR (Yacoub) Bicuspid aortic valve Left ventricular ejection fraction >50% 30–50% 2 mm/year), severe AR or mitral valve regurgitation and desire for pregnancy were present [10]. For patients with bicuspid valves, the threshold recently changed from 50 to 55 mm in the absence of other risk factors according to the latest ESC guidelines on valvular heart disease (version 2012) [11]. The aortic annulus was considered dilated >25 mm for adult patients.
Surgical technique The first 11 patients had the aortic valve reimplanted into a straight vascular prosthesis (Hemashield™ by Maquet, Rastat, Germany) (size range: 26–34 mm) of which one-third (4) were implanted in adolescents. In these patients, the Stanford modification of the ‘David-V’ valve-sparing procedure was performed as described by Demers and Miller [12]. Since 2003, the next 86 patients had the aortic valve implanted into the Valsalva prosthesis (Gelweave Valsalva™ by Sultzer Vascutek, Renfrewshire, Scotland) (size range: 26–32 mm) with a modified reimplantation technique as described by Pacini et al. [13] and the group of de Kerchove et al. [14].
Graft sizing and preserving root geometry After installing cardiopulmonary bypass, aortic clamping and complete cardioplegic arrest a transverse aortotomy was performed 1 cm above the sinotubular junction (STJ). The ascending aorta was resected, leaving a 1 cm collar for the distal anastomosis. Stay sutures were placed at the top of the commissures (4–0 polypropylene) and notice was taken whether the tops of the commissures were situated in one horizontal plane or not. Cusps were inspected for fenestrations that might interfere with a valve-sparing procedure, after which cuspal geometric height was measured. Large central fenestrations (>50% of coapatation area) were regarded as contraindication for a valve-sparing procedure while smaller fenestrations (
ORIGINAL ARTICLE
European Journal of Cardio-Thoracic Surgery (2014) 1–7 doi:10.1093/ejcts/ezu167
David R. Koolbergena,b,‡*, Johan S. J. Manshandena,‡, Berto J. Boumac, Nico A. Blomd, Barbara J. M. Mulderc, Bas A. J. M. de Mola and Mark G. Hazekampa,b a b c d
Department of Cardiothoracic Surgery, Academic Medical Center, Amsterdam, Netherlands Department of Paediatric Cardiology, Leiden University Medical Center, Leiden, Netherlands Department of Cardiology, Academic Medical Center, Amsterdam, Netherlands Department of Paediatric Cardiology, Academic Medical Center, Amsterdam, Netherlands
* Corresponding author. Department of Cardiothoracic Surgery, Academic Medical Center Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands. Tel: +31-20-5669111; fax: +31-20-6962289; e-mail: [email protected] (D.R. Koolbergen). Received 14 October 2013; received in revised form 28 February 2014; accepted 7 March 2014
Abstract OBJECTIVES: To evaluate our results of valve-sparing aortic root replacement and associated (multiple) valve repair. METHODS: From September 2003 to September 2013, 97 patients had valve-sparing aortic root replacement procedures. Patient records and preoperative, postoperative and recent echocardiograms were reviewed. Median age was 40.3 (range: 13.4–68.6) years and 67 (69.1%) were male. Seven (7.2%) patients were younger than 18 years, the youngest being 13.4 years. Fifty-four (55.7%) had Marfan syndrome, 2 (2.1%) other fibrous tissue diseases, 15 (15.5%) bicuspid aortic valve and 3 (3.1%) had earlier Fallot repair. The reimplantation technique was used in all, with a straight vascular prosthesis in 11 (26–34 mm) and the Valsalva prosthesis in 86 (26–32 mm). Concomitant aortic valve repair was performed in 43 (44.3%), mitral valve repair in 10 (10.3%), tricuspid valve repair in 5 (5.2%) and aortic arch replacement in 3 (3.1%). RESULTS: Mean follow-up was 4.2 ± 2.4 years. Follow-up was complete in all. One 14-year old patient died 1.3 years post-surgery presumably of ventricular arrhythmia. One patient underwent reoperation for aneurysm of the proximal right coronary artery after 4.9 years and 4 patients required aortic valve replacement, 3 of which because of endocarditis after 0.1, 0.8 and 1.3 years and 1 because of cusp prolapse after 3.8 years. No thrombo-embolic complications occurred. Mortality, root reoperation and aortic regurgitation were absent in 88.0 ± 0.5% at 5-year follow-up. CONCLUSIONS: Results of valve-sparing root replacement are good, even in association with a high incidence of concomitant valve repair. Valve-sparing aortic root replacement can be performed at a very young age as long as an adult size prosthesis can be implanted. Keywords: Aortic valve repair • Aortic valve preservation • Valve-sparing root replacement
INTRODUCTION Long-term results of valve-sparing root replacement (VSRR) are very encouraging, both in degenerative aneurysm disease [1, 2] as well as in connective tissue disorder [3, 4]. Consequently, indications and applications are expanding [5–7] and the valve-sparing operation is incorporated more and more into the routine practice of the general and congenital cardiac surgeon. Nonetheless, different surgeons are still searching for further improvements to optimize the valve-sparing aortic root replacement technique [8, 9]. In our centre for congenital heart disease Amsterdam–Leiden (CAHAL), we are gaining experience in performing elective valvesparing operations for treatment of aortic root aneurysm in adults and adolescents with connective tissue disorders, valve pathology and congenital heart defects. In this series, a high number of concomitant valve repairs and other surgical procedures were performed. With the use of the Valsalva graft (Gelweave Valsalva™ by † Presented at the 27th Annual Meeting of the European Association for CardioThoracic Surgery, Vienna, Austria, 5–9 October 2013. ‡ The first two authors contributed equally to this work.
Sultzer Vascutek, Renfrewshire, Scotland) a fast and reproducible technique was developed in order to keep cross-clamp and bypass times within safe limits for multiple procedure cardiac surgery. An efficient modification of sub-commissural annuloplasty is presented that we used in patients in whom aortic annulus reduction was required. With this study our short to mid-term results are evaluated.
PATIENTS AND METHODS Study design Aortic valve-sparing operations were performed in a total number of 97 adolescent and adult patients (mean age 38.4 ± 12.8 years; range: 13.4–68.6 years; minimal body weight ≥50 kg) with congenital heart disease at the Academic Medical Centre in Amsterdam and Leiden University Medical Center from September 2003 to September 2013. All patients had aortic valve-sparing root replacement by means of reimplantation of the aortic valve into a vascular
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
CONGENITAL
Valve-sparing aortic root replacement†
2
D.R. Koolbergen et al. / European Journal of Cardio-Thoracic Surgery
prosthesis. Two surgeons at two locations performed the surgery. A retrospective study was performed analysing patient records and preoperative, postoperative and recent echocardiograms.
Patient characteristics Patient characteristics and preoperative clinical profile are listed in Table 1. Clinical diagnoses were Marfan syndrome in 54 (55.7%), Loeys–Dietz in 2 (2.2%) and bicuspid aortic valve in 15 (15.5%). Three patients received VSRR late after tetralogy of Fallot correction; one after a previous Yacoub procedure; another one late after a Ross procedure and five after repair of aortic coarctation in childhood. Preoperative aortic root diameter was 49.5 ± 4.9 mm and mean preoperative annular diameter was 27.1 ± 3.0 mm. Preoperative left ventricular ejection fraction (LVEF) was >50% in 90 (92.8%), 30–50% in 7 (7.2%) and 30 Smoking Diabetes Hypertension High cholesterol Chronic obstructive lung disease EuroSCORE (r) ± SD Previous surgery: Total Fallot correction Ross procedure Aortic coarctationa VSRR (Yacoub) Bicuspid aortic valve Left ventricular ejection fraction >50% 30–50% 2 mm/year), severe AR or mitral valve regurgitation and desire for pregnancy were present [10]. For patients with bicuspid valves, the threshold recently changed from 50 to 55 mm in the absence of other risk factors according to the latest ESC guidelines on valvular heart disease (version 2012) [11]. The aortic annulus was considered dilated >25 mm for adult patients.
Surgical technique The first 11 patients had the aortic valve reimplanted into a straight vascular prosthesis (Hemashield™ by Maquet, Rastat, Germany) (size range: 26–34 mm) of which one-third (4) were implanted in adolescents. In these patients, the Stanford modification of the ‘David-V’ valve-sparing procedure was performed as described by Demers and Miller [12]. Since 2003, the next 86 patients had the aortic valve implanted into the Valsalva prosthesis (Gelweave Valsalva™ by Sultzer Vascutek, Renfrewshire, Scotland) (size range: 26–32 mm) with a modified reimplantation technique as described by Pacini et al. [13] and the group of de Kerchove et al. [14].
Graft sizing and preserving root geometry After installing cardiopulmonary bypass, aortic clamping and complete cardioplegic arrest a transverse aortotomy was performed 1 cm above the sinotubular junction (STJ). The ascending aorta was resected, leaving a 1 cm collar for the distal anastomosis. Stay sutures were placed at the top of the commissures (4–0 polypropylene) and notice was taken whether the tops of the commissures were situated in one horizontal plane or not. Cusps were inspected for fenestrations that might interfere with a valve-sparing procedure, after which cuspal geometric height was measured. Large central fenestrations (>50% of coapatation area) were regarded as contraindication for a valve-sparing procedure while smaller fenestrations (
