Modified valve-sparing reimplantation technique for para-commissural coronary ostia

In some patients undergoing a valve-sparing reimplantation technique, a coronary ostium may be very close to one of the commissures. This condition jeopardizes the coronary ostium patency and valve reimplantation. The authors describe a simple and safe modification of the reimplantation technique, leaving the misplaced coronary ostium attached to the commissure

Aortic valve repair with patch in non-rheumatic disease: indication, techniques and durability†

OBJECTIVES: To analyse the long-term outcomes of aortic valve (AV) repair with biological patch in patient with non-rheumatic valve disease. METHODS: From 1995 to 2011, 554 patients underwent elective (AV) repair; among them, 57 (mean age 45 ± 17 years) had cusp restoration using patch for non-rheumatic valve disease. Seven (12%) patients had unicuspid valve, 30 (53%) patients had bicuspid valve and 20 (35%) had tricuspid valve. Autologous pericardium was used in 26 patients (7 treated, 19 non-treated), bovine pericardium in 26, autologous tricuspid valve leaflet in 4 and aortic homograft cusp in 1. Patching was used to repair perforation (n = 20, 35%), commissural defect (n = 18, 32%), raphe repair (n = 17, 30%) or for cusp extension (n = 2, 3.5%). Echocardiographic and clinical follow-up was 98% complete and mean follow-up was 72 ± 42.5 months. RESULTS: No hospital mortality. At 8 years, overall survival was 90 ± 5% and freedom from valve-related death was 96 ± 3%. Two patients (3.5%) needed early reoperation for aortic regurgitation (AR); they underwent re-repair and the Ross procedure, respectively. Late reoperation was necessary in 9 patients (16%) for AR (n = 4), stenosis (n = 3) or mixed disease (n = 2). They had the Ross procedure (n = 6) or prosthetic valve replacement (n = 3) with no mortality. At 8 years, freedom from reoperation was 75 ± 9%. Freedom from reoperation was slightly higher in tricuspid compared with non-tricuspid valves (92 ± 7 vs 68 ± 11%, P = 0.18) and slightly higher for bovine (95 ± 5%) compared with autologous pericardium (73 ± 11%, P = 0.38), but differences were statistically not significant. In tricuspid valves, freedom from reoperation was higher in perforation repair compared with other techniques (100 vs 50 ± 35%, P = 0.02). In bicuspid valves, freedom from reoperation was similar between different repair techniques (P = 0.38). Late echocardiography showed AR 0-1 in 30 (53%) patients, AR 2 in 12 (21%) and no AR ≥ 3. Three patients presented a mean transvalvular gradient of 30-40 mmHg. Thromboembolic events occurred in 2 patients (0.6%/patient-year), bleeding events in 1 (0.3% /patient-year) and no endocarditis occurred. CONCLUSIONS: AV repair with biological patch is feasible for various aetiologies. The techniques are safe and medium-term durability is acceptable, even excellent for perforation repair in tricuspid valve morphology. Bovine pericardium is a good alternative to autologous pericardium

Redo Root Replacement using the Ross in Valsalva Technique.

The Ross procedure is an alternative option for young and middle-aged patients needing aortic valve replacement. We present an interesting case where the patient had a preexisting aortic homograft that was implanted because of previous infective endocarditis with aortic root abscess. The patient presented with biological degeneration of the homograft with resultant severe stenosis as well as insufficiency. We performed a redo root surgery to replace the homograft with the Ross procedure by using the autograft inclusion into a vascular graft technique. The dissection was carried out by performing external dissection of the aortic root. Redo root replacement is a difficult procedure, however external root dissection is a safe and easy technique that can be used in such a difficult scenario

Valve sparing: aortic root replacement with the reimplantation technique

Aortic valve-sparing procedures are alternative options to aortic valve replacement in patients with aortic root aneurysm and/or severe aortic regurgitation reducing the risk of prosthesis-related complications, such as thromboembolism, and have no need for long-term oral anticoagulation. However, these techniques are technically demanding and long-term results are highly dependent on perfect intraoperative restoration of valve function. We describe a systematic approach to aortic valve-sparing aortic root replacement with the reimplantation technique the way it is currently performed in our institution

Ross operation after failed valve-sparing reimplantation: pulmonary autograft inclusion into the previously implanted Valsalva graft.

Aortic valve dysfunction after valve-sparing root replacement is rare, and the risk depends mainly on the quality of the valve at the time of surgery. If reoperation is needed, the surgical options are a valve replacement inside the graft or a Bentall procedure. Because of the young age of these patients, a Ross operation seems feasible, considering such advantages as durability and avoidance of lifelong anticoagulation treatment. Nevertheless, one must take into consideration autograft harvesting difficulties and root dissection risks. [...

Techniques in trileaflet aortic valve repair

Surgical techniques for regurgitant aortic valve pathology have evolved significantly in the last 20 years as a result of deeper understanding of functional structure and physiopathology of the aortic valve and the development of a common anatomical and functional language among specialists. The introduction of the functional classification of aortic valve regurgitation facilitated the development of standard surgical approaches to treat this pathology. The principles of aortic valve repair include the restoration of normal anatomy and geometry of the functional aortic root with the aim to provide a long-term stabilisation of the aortic annulus. We report a review of our approach and surgical techniques to repair the aortic valve and aortic root based on our long experience in the field