Reimplantation versus remodelling with ring annuloplasty: comparison of mid-term outcomes after valve-sparing aortic root replacement†

Lenoir, Marien; Maesen, Bart; Stevens, Louis-Mathieu; Cartier, Raymond; Demers, Philippe; Poirier, Nancy; Tousch, Michael; El-Hamamsy, Ismaı̈l

doi:10.1093/ejcts/ezy016

Cited by 32 publications

(15 citation statements)

References 18 publications

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“…Although both the remodeling and reimplantation operations spare the aortic valve, the remodeling technique alone does not address or prevent further annular dilation, although the addition of an annuloplasty ring may be effective. 3 Some studies have suggested that the remodeling technique, which also spares the shape of the sinuses of Valsalva, results in more natural aortic root biomechanics. 4 , 5 However, reimplantation of the aortic valve addresses annular dilation and externally supports any remaining abnormal valvular tissue, and in some series, demonstrates greater long-term durability.…”

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confidence: 99%

Comprehensive Ex Vivo Comparison of 5 Clinically Used Conduit Configurations for Valve-Sparing Aortic Root Replacement Using a 3-Dimensional–Printed Heart Simulator

et al. 2020

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Background: Many graft configurations are clinically used for valve-sparing aortic root replacement, some specifically focused on recapitulating neosinus geometry. However, the specific impact of such neosinuses on valvular and root biomechanics and the potential influence on long-term durability are unknown. Methods: Using a custom 3-dimenstional–printed heart simulator with porcine aortic roots (n=5), the anticommissural plication, Stanford modification, straight graft (SG), Uni-Graft, and Valsalva graft configurations were tested in series using an incomplete counterbalanced measures design, with the native root as a control, to mitigate ordering effects. Hemodynamic and videometric data were analyzed using linear models with conduit as the fixed effect of interest and valve as a fixed nuisance effect with post hoc pairwise testing using Tukey’s correction. Results: Hemodynamics were clinically similar between grafts and control aortic roots. Regurgitant fraction varied between grafts, with SG and Uni-Graft groups having the lowest regurgitant fractions and anticommissural plication having the highest. Root distensibility was significantly lower in SG versus both control roots and all other grafts aside from the Stanford modification ( P ≤0.01 for each). All grafts except SG had significantly higher cusp opening velocities versus native roots ( P <0.01 for each). Relative cusp opening forces were similar between SG, Uni-Graft, and control groups, whereas anticommissural plication, Stanford modification, and Valsalva grafts had significantly higher opening forces versus controls ( P <0.01). Cusp closing velocities were similar between native roots and the SG group, and were significantly lower than observed in the other conduits ( P ≤0.01 for each). Only SG and Uni-Graft groups experienced relative cusp closing forces approaching that of the native root, whereas relative forces were >5-fold higher in the anticommissural plication, Stanford modification, and Valsalva graft groups. Conclusions: In this ex vivo modeling system, clinically used valve-sparing aortic root replacement conduit configurations have comparable hemodynamics but differ in biomechanical performance, with the straight graft most closely recapitulating native aortic root biomechanics.

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confidence: 99%

Comprehensive Ex Vivo Comparison of 5 Clinically Used Conduit Configurations for Valve-Sparing Aortic Root Replacement Using a 3-Dimensional–Printed Heart Simulator

et al. 2020

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“…By reconstructing the aortic root with a remodeling technique, the native aortic sinus and physiological cusp motions can be preserved when an external subvalvular aortic annuloplasty stabilizes the ventriculo-aortic junction, which combines both the advantages of remodeling and reimplantation (43,44). A study in 2018 reported that the 5-year outcomes of remodeling technique combining external ring annuloplasty were comparable with the reimplantation technique, with a survival of 100%, a freedom from valverelated reoperation of 97%±2% and a freedom from aortic insufficiency ≥2 or reoperation of 84%±5% (45). But longer follow-up times and larger sample sizes are still required before a final conclusion can be drawn.…”

Section: Discussionmentioning

confidence: 99%

Reimplantation versus remodeling in valve-sparing surgery for aortic root aneurysms: a meta-analysis

et al. 2020

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Background: Valve-sparing aortic root replacement (VSARR), which includes reimplantation and remodeling techniques, has been developed as an important treatment for aortic root aneurysms. We aimed to evaluate the outcomes of reimplantation versus remodeling techniques in valve-sparing surgery for aortic root aneurysms. Methods: A systematic review and meta-analysis was performed by searching PubMed, Embase and the Cochrane Library until November 2019. Fourteen retrospective cohort studies comparing reimplantation with remodeling techniques for aortic root aneurysms were included and contained at least one of the following outcomes: early mortality, late mortality, aortic valve-related reoperation, and postoperative moderate to severe aortic regurgitation (AR). Results: The outcomes of 1,672 patients (1,011 underwent reimplantation surgery, and 661 underwent remodeling) were analyzed. Compared with remodeling, the reimplantation technique was associated with a significantly lower risk of late mortality (RR =0.34; 95% CI, 0.17-0.71; P=0.004; I 2 =37%) and reoperation (RR =0.31; 95% CI, 0.12-0.76; P=0.01; I 2 =55%). There was no significant difference in early mortality (RR =0.69; 95% CI, 0.31-1.53; P=0.36; I 2 =0%), postoperative moderate to severe AR (RR =0.64; 95% CI, 0.31-1.32; P=0.22; I 2 =36%) or postoperative stroke (RR =1.26; 95% CI, 0.58-2.75; P=0.56; I 2 =0%) between the two groups. No evidence of publication bias was detected. Conclusions: The current meta-analysis indicate that patients who undergo reimplantation procedures have a significantly lower risk of late mortality and reoperation than those who undergo remodeling procedures. Early mortality, postoperative moderate to severe AR and stroke were comparable between the two techniques.

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“…For a long time, the main discussion about VSRR technique was around the question of remodeling versus reimplantation. Overall, long-term results following both procedures are excellent (27,37,38). Nevertheless, early results suggested higher rates of reintervention in patients who underwent a remodeling procedure (6,39,40).…”

Section: Surgical Techniquementioning

confidence: 98%

“…Importantly, the principles of surgical repair associated with VSRR using either technique are clearly defined: stabilization of the aortic annulus (basal ring), creation of neo-sinuses of Valsalva, reduction and stabilization of the STJ and restoration of cusp geometry within the new aortic root (46,47). All these basic principles can be achieved with equal effectiveness using either a reimplantation procedure or a remodeling procedure with aortic annuloplasty (11,27,37,41). One of the critical elements to obtaining good results however is the issue of surgeon and center expertise.…”

Section: Surgical Techniquementioning

confidence: 99%

Aortic valve sparing surgery—patient selection and techniques

Chauvette¹,

Chamberland²,

Lefebvre³

et al. 2021

J Vis Surg

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Aortic valve sparing root replacement (VSRR) is an attractive alternative to composite graft replacement in young patients with root aneurysms. The preservation of a native aortic valve provides more physiologic hemodynamics, avoids the complications associated with valve replacement and is associated with excellent long-term survival. However, this has to be weighed against the risk of reintervention due to valve repair failure in specific patients. This can be optimized through careful patient selection and surgical technique. The aim of this article is to review these important considerations for planning VSRR.

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Reimplantation versus remodelling with ring annuloplasty: comparison of mid-term outcomes after valve-sparing aortic root replacement†

Abstract: Despite a higher prevalence of bicuspid aortic valves and larger aortic annular diameters, mid-term outcomes after remodelling with extra-aortic annuloplasty and reimplantation are comparable. Extra-aortic ring annuloplasty is effective at stabilizing annular dimensions.

Cited by 32 publications

References 18 publications

Comprehensive Ex Vivo Comparison of 5 Clinically Used Conduit Configurations for Valve-Sparing Aortic Root Replacement Using a 3-Dimensional–Printed Heart Simulator

Comprehensive Ex Vivo Comparison of 5 Clinically Used Conduit Configurations for Valve-Sparing Aortic Root Replacement Using a 3-Dimensional–Printed Heart Simulator

Reimplantation versus remodeling in valve-sparing surgery for aortic root aneurysms: a meta-analysis

Aortic valve sparing surgery—patient selection and techniques

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