Aortic root replacement with the stentless Freestyle bioprosthesis

In this video tutorial, the technical details for the implantation of the Freestyle stentless bioprosthesis are outlined based on the case of a 76-year-old male patient with symptomatic stenosis of a bicuspid aortic valve and aortic root dilatation

The Aortic Root in Acute Type A Dissection: Repair or Replace?

Background: The effect of an “aggressive” approach on the aortic root in acute type A aortic dissection (ATAAD) remains insufficiently explored. Methods: Retrospective analysis was conducted between 1992 and 2020 of a single-center, prospective cohort of consecutive patients aged ≥18 years diagnosed with ATAAD. Patients were divided into 2 groups: aortic root replacement (ARR; prosthetic or valve-sparing root replacement, n = 141) and conservative root approach (CRA; root sparing of partially dissected root, n = 90; and supracoronary ascending replacement in nondissected root, n = 68). Inverse probability weighting was used to compare patients with different preoperative characteristics. Mean follow-up was 5.1 (0-21) years in ARR and 7.1 (0-25) years in CRA. Results: The frequency of ARR increased over the years, with 19% and 78% of patients undergoing ARR in the earliest and most recent periods, respectively. Early mortality decreased over the years, despite a more aggressive approach, and remained lower in ARR. CRA was associated with a higher hazard of late mortality (hazard ratio, 1.38; 95% CI, 1.12-1.68; P = .001) and reintervention (hazard ratio, 2.08; 95% CI, 1.44-3.56; P = .001). After CRA, new-onset aortic valve insufficiency was a common cause of reintervention. Conclusions: Over the years, there was a gradual increase in the root replacement approach in ATAAD. Root replacement was associated with better long-term survival and fewer reinterventions compared with the conservative approach, whereas the in-hospital mortality decreased during these years. Hence, aggressive root replacement is safe and may be applied in ATAAD with good long-term clinical results, without increased hospital mortality

Bentall Procedure: A Systematic Review and Meta-Analysis

Background. The Bentall procedure is considered the gold standard in the treatment of patients requiring aortic root replacement. An up-to-date overview of outcomes after the Bentall procedure is lacking. Methods. We conducted a systematic review and meta-analysis of characteristics of and long-term outcome after the Bentall procedure with a mechanical valve prosthesis. Pooling was performed using the inverse variance method within a random-effects model. Outcome events are reported as linearized occurrence rates (percentage per patient year) with 95% confidence intervals. Results. In total, 46 studies with 7,629 patients (mean age, 50 years; 76% men) were selected. Pooled early mortality was 6% (422 patients). During a mean follow-up of 6 years (49,175 patient-years), the annual linearized occurrence rate for late mortality was 2.02% (1.77%-2.31%; 892 patients), for aortic root reoperation it was 0.46% (0.36%-0.59%), for hemorrhage it was 0.64% (0.47%-0.87%), for thromboemboli it was 0.77% (0.60%-1.00%), for endocarditis it was 0.39% (0.33%-0.46%), and for major adverse valve-related events it was 2.66% (2.17%-3.24%). Operations performed in more recent years were associated with lower rates of aortic root reoperation (beta = -0.452; p = 0.015). Conclusions. This systematic review illustrates that rates of aortic root reoperation after the Bentall procedure have decreased over the years. However, late mortality, major bleeding, and thromboembolic complications remain a concern. This report may be used to benchmark the potential therapeutic benefit of novel surgical approaches, such as valve-sparing aortic root replacement. (C) 2016 by The Society of Thoracic Surgeon

Reported Outcome After Valve-Sparing Aortic Root Replacement for Aortic Root Aneurysm: A Systematic Review and Meta-Analysis

Valve-sparing aortic root techniques have progressively gained ground in the treatment of aortic root aneurysm and aortic insufficiency. By avoiding anticoagulation therapy they offer a good alternative to composite graft replacement. This systematic review describes the reported outcome of valve-sparing aortic root replacement, focusing on the remodeling and reimplantation technique. A systematic literature search on the characteristics of and outcomes after valve-sparing aortic root replacement revealed 1,659 articles. The inclusion criteria were a focus on valve-sparing aortic root replacement in adults with aortic root aneurysm, presentation of survival data, and inclusion of at least 30 patients. Data were pooled by inverse variance weighting and analyzed by linear regression. Of 1,659 articles published between January 1, 2000, and January 1, 2014, 31 were included (n = 4,777 patients). The mean age at operation was 51 +/- 14.7 years, and 14% of patients had a bicuspid aortic valve. The reimplantation technique was used in 72% and remodeling in 27% (1% other). No clinical advantage in terms of survival and reoperation of one technique over the other was found. Cusp repair was performed in 33%. Pooled early mortality was 2% (n = 103). During follow-up (21,716 patient-years), 262 patients died (survival 92%), and 228 (5%) underwent reoperation, mainly valve replacement. Major adverse valve-related events were low (1.66% patient-years). Preoperative severe aortic valve regurgitation showed a trend toward higher reoperation rate. Remodeling and reimplantation techniques show comparable survival and valve durability results, providing a valid alternative to composite valve replacement. The heterogeneity in the data underlines the need for a collaborative effort to standardize outcome reporting. (C) 2015 by The Society of Thoracic Surgeon

The AVP Device: A Tool for Intraoperative Evaluation of Aortic Valve After Repair

Aortic valve repair procedures can be technically challenging and there are no tools to evaluate the valve intraoperatively. Echocardiography after repair is considered the standard method, but if there are no satisfactory results, another clamp session is needed. There is an unmet need for an intraoperative evaluation tool similar to the “water test” in mitral valvuloplasty.The AVP device is an intraoperative aortic valve visualization and pressurization device. It enables valve inspection and evaluation under physiological conditions and it allows measurements of potential aortic valve regurgitation.The AVP device has been used in 26 patients undergoing valve-sparing root replacement with the reimplantation technique. In 24 patients, postoperative valvular regurgitation was less than grade 1. In three of these patients, additional targeted adjustments were performed. The median leakage measured was 90 ml/min with IQR 55 – 120 ml/min. In two patients with complex anatomy, the valve was replaced after evaluation with the AVP device (300 ml/min).This novel AVP device enables intraoperative evaluation of valve repair procedures in different physiological conditions. Visualization of the valve before reimplantation of the coronary arteries allows for targeted adjustments on the valve and prevents extra CPB and cardiac arrest time in case of failed repair. It is easy to use and makes valve-sparing procedures more accessible.Reference(s)• Aortic valve visualization and pressurization device: A novel device for intraoperative evaluation of aortic valve repair procedures.Arabkhani B, Sandker SC, Braun J, Hjortnaes J, Van Brakel TJ, Koolbergen DR, Klautz RJM, Hazekamp MG.Eur J Cardiothorac Surg. 2023 Aug 23• A multicentre, propensity score matched analysis comparing a valve-sparing approach to valve replacement in aortic root aneurysm: Insight from the AVIATOR databaseB Arabkhani, R.J.M. Klautz, F de Heer, L. De Kerchove, G. El Khoury, E. Lansac, H.J. Schäfers, I. El-Hamamsy, M. Marien Lenoir, J. Aramendi, B. Meuris, P. Verbrugghe, J. Kluin, D.R. Koolbergen, O. Bouchot, I. Rudez, A. Kolesar,T.J. van BrakelEur J Cardiothorac Surg. 2023 Feb 3;63(2):ezac514</p