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In the pursuit of improved outcomes in aortic root surgery, many techniques have been created and iteratively honed over the past five decades. Surgical strategies and their critical adjustments are surveyed, complemented by a summary of recent findings on early and late patient outcomes. Besides, we provide brief accounts of the valve-sparing technique's use in several clinical environments, including scenarios involving high-risk patients with conditions like connective tissue disorders or accompanying dissections.
Owing to the consistently excellent long-term results observed, aortic valve-sparing surgery is now more often chosen for patients who have aortic regurgitation and/or an ascending aortic aneurysm. Subsequently, in patients with a bicuspid valve who require the replacement of aortic sinuses or aortic regurgitation surgery, valve-sparing surgical intervention might be considered when performed at a comprehensive valve center (Class 2b in both the American and European guidelines). Restoring the normal functionality of the aortic valve and the proper configuration of the aortic root is the goal of reconstructive valve surgery. From characterizing unusual valve structures, assessing aortic regurgitation and the underlying processes, to evaluating the quality of tissue valves and the success of surgical results, echocardiography takes center stage. Consequently, notwithstanding the advent of alternative tomographic procedures, 2-dimensional and 3-dimensional echocardiography remains fundamental for patient triage and forecasting the likelihood of a successful repair. In this review, echocardiography plays a key role in detecting abnormalities of the aortic valve and root, assessing aortic valve regurgitation severity, predicting the possibility of valve repair, and evaluating immediate results post-surgery, directly within the operating room. Successfully repairing valves and roots: a practical guide using echocardiographic predictors is presented.
Pathologies of the aortic root, including aneurysm formation, the development of aortic insufficiency, and aortic dissection, are suitable candidates for repair that preserves the valve. Concentric lamellar units, 50 to 70 in number, form the walls of a typical aortic root. Sheets of elastin enclose smooth muscle cells, which are further interspersed with collagen and glycosaminoglycans, making up these units. Medial degeneration causes the extracellular matrix (ECM) to break down, results in the loss of smooth muscle cells, and causes an accumulation of proteoglycans and glycosaminoglycans. Aneurysm formation is a consequence of these structural transformations. Aortic root aneurysms are commonly observed in individuals with hereditary thoracic aortic conditions, including Marfan syndrome and Loeys-Dietz syndrome. A significant hereditary pathway for thoracic aortic diseases involves the transforming growth factor- (TGF-) cell signaling process. Alterations in pathogenic genes involved in various components of this pathway are implicated in the formation of aortic root aneurysms. Secondary effects of aneurysm formation incorporate AI. The heart struggles to cope with the amplified pressure and volume load emanating from prolonged, severe AI-related issues. The absence of surgery presents a poor prognosis for the patient when symptoms develop or significant left ventricular remodeling and dysfunction occur. Medial degeneration and aneurysm formation contribute to a heightened risk of aortic dissection. Type A aortic dissection cases necessitate aortic root surgery in 34-41% of instances. The prediction of who will contract aortic dissection represents an ongoing clinical problem. The critical areas of research are focused on the finite element analysis, study of fluid-structure interactions and aortic wall biomechanics.
With respect to treating root aneurysm, current clinical standards promote valve-sparing aortic root replacement (VSRR) above valve replacement. Single-center studies consistently show that reimplantation is the most common valve-preserving technique, yielding excellent results. The goal of this systematic review and meta-analysis is to offer a complete understanding of clinical outcomes after VSRR using reimplantation, examining possible differences based on the presence of a bicuspid aortic valve (BAV) morphology.
Our systematic literature review encompassed papers published post-2010, detailing outcomes subsequent to VSRR. Studies that only addressed acute aortic syndromes or congenital patients were excluded from the review. Baseline characteristics were presented, with sample size weighting employed for the summary. Late outcomes were synthesized using inverse variance weighting as the method. Aggregated Kaplan-Meier (KM) plots depicting time-to-event trajectories were constructed. Subsequently, a microsimulation model was designed to calculate life expectancy and the probabilities of valve-related ailments arising post-surgery.
A comprehensive analysis encompassed 7878 patients from 44 studies, all meeting the pre-defined inclusion criteria. Surgical intervention occurred at an average age of 50 years for the patients, and almost 80% of them were male. Mortality among the initial patients was 16% when grouped, and the most common complication during surgery was chest re-exploration for bleeding, occurring in 54% of the patients. On average, participants were followed for 4828 years. Aortic valve (AV) related complications, including endocarditis and stroke, exhibited linearized occurrence rates of less than 0.3% per patient-year. One year post-treatment, overall survival reached 99%; however, after ten years, it fell to 89%. Both tricuspid and BAV procedures demonstrated comparable freedom from reoperation outcomes, achieving 99% at one year and 91% at ten years, respectively.
This systematic review and meta-analysis shows impressive short-term and long-term outcomes from valve-sparing root replacement with reimplantation in terms of survival, freedom from reoperation, and the incidence of valve-related complications, showing no variations between tricuspid and bicuspid aortic valve groups.
A rigorous meta-analysis coupled with a systematic review of valve-sparing root replacement employing reimplantation techniques demonstrates excellent results across both short-term and long-term outcomes, including comparable survival rates, freedom from reoperation, and minimal valve-related complications, with no discernible difference between tricuspid and BAV procedures.
Despite their introduction three decades ago, aortic valve sparing operations continue to generate discussion about their appropriateness, reproducibility, and long-term effectiveness. A comprehensive analysis of the long-term outcomes for patients with reimplanted aortic valves is provided in this article.
This study encompassed all patients undergoing tricuspid aortic valve reimplantation at Toronto General Hospital between 1989 and 2019. Prospective clinical monitoring of patients included periodic assessments and imaging of the heart and aorta.
Four hundred and four patients were found during the investigation. A median age of 480 years, encompassing an interquartile range of 350 to 590 years, was observed, and the subset of 310 individuals (767% of the sample) were male. The study group included 150 patients with Marfan syndrome, 20 with Loeys-Dietz syndrome, and a further 33 experiencing acute or chronic aortic dissections. The central tendency of the follow-up period was 117 years, while the interquartile range was 68-171 years. A remarkable 55 patients survived the 20-year period without requiring a subsequent surgical procedure. Following 20 years, a substantial 267% cumulative mortality was observed [95% confidence interval (CI): 206%-342%]. A high incidence of aortic valve reoperation (70%, 95% CI 40-122%) was noted, along with a considerable 118% development of moderate or severe aortic insufficiency (95% CI 85-165%). Expression Analysis No variables were determined to be connected with reoperation of the aortic valve or the emergence of aortic insufficiency. check details Genetic syndromes frequently presented alongside new distal aortic dissections in patients.
Excellent aortic valve function is a hallmark of tricuspid aortic valve reimplantation in patients, sustained during the initial two decades of follow-up. Patients with concurrent genetic syndromes demonstrate a relatively common occurrence of distal aortic dissections.
In patients harboring a tricuspid aortic valve, reimplantation of the aortic valve consistently demonstrates exceptional aortic valve performance during the initial two decades of post-procedure observation. A relatively common finding in patients with genetic syndromes is distal aortic dissections.
More than three decades ago, the initial valve sparing root replacement (VSRR) procedure was detailed. Annular support is prioritized at our institution in cases of annuloaortic ectasia, with reimplantation being the chosen method. The operation's data indicates multiple iterations have been undertaken. Surgical intervention procedures for graft implantation present considerable variability, ranging from graft size determination and inflow suture placement techniques to the chosen strategy of annular plication, stabilization methods, and the ultimate selection of the graft. Ayurvedic medicine Our method, having evolved over the past eighteen years, now utilizes a larger, straight graft, roughly following the original Feindel-David formula, anchored by six inflow sutures, and accompanied by some degree of annular plication for stabilization. The long-term effectiveness of trileaflet and bicuspid heart valves is characterized by infrequent instances of reintervention. For our reimplantation technique, this is a detailed overview.
Throughout the past three decades, the significance of preserving native valves has become progressively more apparent. Valve-sparing root replacement, particularly the reimplantation or remodeling method, is becoming more common in the treatment of aortic root replacement and/or aortic valve repair. In this report, we encapsulate our single-center observations regarding the reimplantation method.