Long-term outcomes of aortic root operations for Marfan syndrome: A comparison of Bentall versus aortic valve-sparing procedures

Price, Joel; Magruder, J. Trent; Young, Allen; Grimm, Joshua C.; Patel, Nishant; Alejo, Diane; Dietz, Harry C.; Vricella, Luca A.; Cameron, Duke E.

doi:10.1016/j.jtcvs.2015.10.068

Cited by 114 publications

(83 citation statements)

References 39 publications

(44 reference statements)

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“…There were 2 studies reporting the outcomes of CVG only (11,19) and 8 studies reporting the outcomes of VSRR only (15,17,20,22,23,26,28,31). Thirteen studies reported outcomes for both CVG and VSRR (12)(13)(14)16,18,21,24,25,27,29,30,32,33). The overall study characteristics are detailed in Table 1.…”

Section: Resultsmentioning

confidence: 99%

“…The current meta-analysis is particularly important because since a previous analysis by Benedetto (8) in 2011 that questioned the efficacy of VSRR in this selective cohort of patients, several important papers have been published which have been included by Flynn and colleagues. Indeed, since then, Dr. David (15) published his experience with Marfan patients as well as the groups of Dr. Cameron (25) in Baltimore (US), Dr. Carrel (27) in Bern (Switzerland), Dr. Sievers (26) in Lubeck (Germany) and others. The current meta-analysis shows clearly that VSRR is associated with particularly low rates of valve-related complications such as bleeding, thromboembolism, endocarditis and an improved survival compared to the conventional Bentall operation.…”

Section: Expert Opinion 4 (Stefano Mastrobuoni and Gebrine El Khoury)mentioning

confidence: 99%

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Systematic review and meta-analysis of surgical outcomes in Marfan patients undergoing aortic root surgery by composite-valve graft or valve sparing root replacement

Flynn

Tian

Wilson-Smith

et al. 2017

Ann. Cardiothorac. Surg.

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Background: A major, life-limiting feature of Marfan syndrome (MFS) is the presence of aneurysmal disease. Cardiovascular intervention has dramatically improved the life expectancy of Marfan patients.Traditionally, the management of aortic root disease has been undertaken with composite-valve graft replacing the aortic valve and proximal aorta; more recently, valve sparing procedures have been developed to avoid the need for anticoagulation. This meta-analysis assesses the important surgical outcomes of the two surgical techniques.Methods: A systematic review and meta-analysis of 23 studies reporting the outcomes of aortic root surgery in Marfan patients with data extracted for outcomes of early and late mortality, thromboembolic events, late bleeding complications and surgical reintervention rates.Results: The outcomes of 2,976 Marfan patients undergoing aortic root surgery were analysed, 1,624 patients were treated with composite valve graft (CVG) and 1,352 patients were treated with valve sparing root replacement (VSRR). When compared against CVG, VSRR was associated with reduced risk of thromboembolism (OR =0.32; 95% CI, 0.16-0.62, P=0.0008), late hemorrhagic complications (OR =0.18; 95% CI, 0.07-0.45; P=0.0003) and endocarditis (OR =0.27; 95% CI, 0.10-0.68; P=0.006). Importantly there was no significant difference in reintervention rates between VSRR and CVG (OR =0.89; 95% CI, 0.35-2.24; P=0.80).Conclusions: There is an increasing body of evidence that VSRR can be reliably performed in Marfan patients, resulting in a durable repair with no increased risk of re-operation compared to CVG, thus avoiding the need for systemic anticoagulation in selected patients.

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Section: Resultsmentioning

confidence: 99%

Section: Expert Opinion 4 (Stefano Mastrobuoni and Gebrine El Khoury)mentioning

confidence: 99%

Systematic review and meta-analysis of surgical outcomes in Marfan patients undergoing aortic root surgery by composite-valve graft or valve sparing root replacement

Flynn

Tian

Wilson-Smith

et al. 2017

Ann. Cardiothorac. Surg.

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“…Several authors have reported on the results of AVsparing root replacement in the setting of Marfan patients (3)(4)(5)(6). Dr. David (3) recently reported on his 20-year experience with the valve-sparing root replacement procedures in Marfan patients.…”

Section: Commentsmentioning

confidence: 99%

Aortic valve repair in patients with Marfan syndrome—the “Brussels approach”

Mastrobuoni

Tamer

Navarra

et al. 2017

Ann. Cardiothorac. Surg.

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“…14,15 Other studies using the VG with long-term follow-up, including a multi-institutional, multisurgeon trial, reported freedom from reoperation between 89% and 94% at 4 years. [16][17][18][19] Because of various modifications of the David procedure using SGs (with or without plication, necking graft down, etc) or switching to the VG midway through the study period, it is difficult to compare isolated repairs using unmodified SGs versus those with neosinuses added because these are typically grouped together in the same category of reimplantation (vs remodeling, which most of these studies sought to compare). Studies using cylindrical grafts (with or without modification) report 5-year freedom from reoperation between 91% and 98% and those reporting exclusive use of the David I technique (SG without modification) report 91%-97% freedom from reoperation at 5 years.…”

mentioning

confidence: 99%

Modeling conduit choice for valve-sparing aortic root replacement on biomechanics with a 3-dimensional–printed heart simulator

Paulsen

Kasinpila

Imbrie-Moore

et al. 2019

The Journal of Thoracic and Cardiovascular Surgery

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Objective: The optimal conduit for valve-sparing aortic root replacement is still debated, with several conduit variations available, ranging from straight tubular grafts to Valsalva grafts. Benefits of neosinus reconstruction include enhanced flow profiles and improved hemodynamics. Curiously, however, some clinical data suggest that straight grafts may have greater long-term durability. In this study, we hypothesized that straight tubular grafts may help maintain the native cylindrical position of the aortic valve commissures radially, resulting in preserved leaflet coaptation, reduced stresses, and potentially improved valve performance.Methods: Using 3D printing, a left heart simulator with a valve-sparing root replacement model and a physiologic coronary circulation was constructed. Aortic valves were dissected from fresh porcine hearts and reimplanted into either straight tubular grafts (n ¼ 6) or Valsalva grafts (n ¼ 6). Conduits were mounted into the heart simulator and hemodynamic, echocardiographic, and high-speed videometric data were collected.Results: Hemodynamic parameters and coronary blood flow were similar between straight and Valsalva grafts, although the former were associated with lower regurgitant fractions, less peak intercommissural radial separation, preserved leaflet coaptation, decreased leaflet velocities, and lower relative leaflet forces compared with Valsalva grafts.Conclusions: Valsalva grafts and straight grafts perform equally well in terms of gross hemodyanics and coronary blood flow. Interestingly, however, the biomechanics of these 2 conduits differ considerably, with straight grafts providing increased radial commissural stability and leaflet coaptation. Further investigation into how these parameters influence clinical outcomes is warranted. (J Thorac Cardiovasc Surg 2019;158:392-403) Variation (yellow arrows) between Valsalva graft and radial position of aortic commissures. Central MessageStraight grafts maintain the radial position of the aortic valve commissures in their native cylindrical conformation, preserving leaflet coaptation and decreasing regurgitation, cusp velocities, and forces. PerspectiveValve-sparing root replacement is an effective treatment for aortic root aneurysms, although the ideal conduit is unknown. While neosinus reconstruction is believed to generate more physiologic flow profiles and optimized hemodynamics, it does not appear to increase longterm clinical durability over straight grafts. Ex vivo testing was used to provide a mechanistic comparison and demonstrated decreased cusp velocities, forces, and regurgitation in straight grafts.

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Long-term outcomes of aortic root operations for Marfan syndrome: A comparison of Bentall versus aortic valve-sparing procedures

Cited by 114 publications

References 39 publications

Systematic review and meta-analysis of surgical outcomes in Marfan patients undergoing aortic root surgery by composite-valve graft or valve sparing root replacement

Systematic review and meta-analysis of surgical outcomes in Marfan patients undergoing aortic root surgery by composite-valve graft or valve sparing root replacement

Aortic valve repair in patients with Marfan syndrome—the “Brussels approach”

Modeling conduit choice for valve-sparing aortic root replacement on biomechanics with a 3-dimensional–printed heart simulator

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