Valve-sparing aortic root repair without down-sizing of the annulus

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Valve-sparing aortic root repair without down-sizing of the annulus Paul P. Urbanski, MD, PhD, Xiaochun Zhan, MD, Husam Hijazi, MD, Michael Zacher, MD, Anno Diegeler, MD, PhD The Journal of Thoracic and Cardiovascular Surgery Volume 143, Issue 2, Pages 294-302.e1 (February 2012) DOI: 10.1016/j.jtcvs.2011.10.056 Copyright © 2012 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Left, Actuarial survival without aortic valve replacement. Right, Freedom from relevant (≥3+) aortic insufficiency (AI) and/or aortic valve replacement (AVR). Note that in the series presented all patients with relevant AI underwent AVR. The Journal of Thoracic and Cardiovascular Surgery 2012 143, 294-302.e1DOI: (10.1016/j.jtcvs.2011.10.056) Copyright © 2012 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Computed tomographic angiogram and echocardiogram of a 32-year-old patient with Marfan disease without aortic regurgitation showing physiologic proportions between the annulus (29 mm) and cusp sizes despite root enlargement. The Journal of Thoracic and Cardiovascular Surgery 2012 143, 294-302.e1DOI: (10.1016/j.jtcvs.2011.10.056) Copyright © 2012 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Preoperative (upper row) and postoperative (bottom row) transesophageal echocardiograms showing central aortic regurgitation in a 38-year-old patient with pronounced dilatation of the right and noncoronary sinuses and an annulus size of 30 mm. The regurgitation was completely abolished after isolated repair of dilated sinuses using the single-patch technique. The Journal of Thoracic and Cardiovascular Surgery 2012 143, 294-302.e1DOI: (10.1016/j.jtcvs.2011.10.056) Copyright © 2012 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 Schematic illustration showing mechanisms of aortic root and valve repair. Upper row, Downsizing (arrows) the complete aortic root (including annulus) improves cusp coaptation but does not normalize it. Middle row, By shortening the free margin, cusp height can be increased (single arrow), if necessary, but its effective surface becomes more restricted, necessitating drastic downsizing (double arrows). This may lead to folding of unchanged cusps and hindering of valve motion. Bottom row, Remodeling the aortic root and restoring cusp size with pericardium (see also Figure 6). The Journal of Thoracic and Cardiovascular Surgery 2012 143, 294-302.e1DOI: (10.1016/j.jtcvs.2011.10.056) Copyright © 2012 The American Association for Thoracic Surgery Terms and Conditions

Figure 5 Upper row, Preoperative transesophageal echocardiogram of a 63-year-old patient with dilatation of the right and noncoronary sinuses and aortic regurgitation caused by prolapse and secondary restriction of the left coronary cusp. Aortic annulus: 29 mm. Middle row, Postoperative transesophageal echocardiogram after repair of right and noncoronary sinuses, reinforcement of left coronary cusp free margin with continuous polytetrafluoroethylene suture, and subcommissural annuloplasty. Bottom row, left, Transesophageal control echocardiogram after 10 months showing recurrent regurgitation caused by progressive restriction of the left coronary cusp without any changes of aortic root size and shape. Bottom row, right, Aortic valve cusps excised during redo surgery showing progressive restriction of left coronary cusp. The Journal of Thoracic and Cardiovascular Surgery 2012 143, 294-302.e1DOI: (10.1016/j.jtcvs.2011.10.056) Copyright © 2012 The American Association for Thoracic Surgery Terms and Conditions

Figure 6 Upper row, Preoperative transesophageal echocardiograms of a 58-year-old patient with dilatation of the right and noncoronary sinuses and severe aortic insufficiency caused by prolapse and secondary restriction of the right coronary cusp. Aortic annulus: 30 mm. Bottom row, Postoperative transesophageal echocardiograms after repair of the right coronary cusp using autologous pericardium and isolated repair of dilated sinuses using the single-patch technique. The Journal of Thoracic and Cardiovascular Surgery 2012 143, 294-302.e1DOI: (10.1016/j.jtcvs.2011.10.056) Copyright © 2012 The American Association for Thoracic Surgery Terms and Conditions

Figure E1 Graphic showing rates of aortic root repair using the single-patch technique (continuous line) and complete aortic root replacements with valved conduits (dotted line). For details, see text. The Journal of Thoracic and Cardiovascular Surgery 2012 143, 294-302.e1DOI: (10.1016/j.jtcvs.2011.10.056) Copyright © 2012 The American Association for Thoracic Surgery Terms and Conditions