Surgical Treatment of Annuloaortic Ectasia – Replace or Repair?

Abstract

Background: Patients with annuloaortic ectasia may be surgically treated with modified Bentall or David I valve-sparing procedures. Here, we compared the long-term results of these procedures. Methods: A total of 181 patients with annuloaortic ectasia underwent modified Bentall (102 patients, Group 1) or David I (79 patients, Group 2) procedures from 1994 to 2015. Mean age was 62 ± 11 years in Group 1 and 64 ± 16 years in Group 2. Group 1 patients were in poorer health, with a lower ejection fraction and higher functional class. Results: Early mortality was 3% in Group 1 and 2.5% in Group 2. Patients undergoing a modified Bentall procedure had a higher incidence of thromboembolism and hemorrhage, whereas those undergoing a David I procedure had a higher incidence of endocarditis. Actuarial survival was 70 ± 6% at 15 years in Group 1 and 84 ± 7% at 10 years in Group 2. Actuarial freedom from reoperation was 97 ± 2% at 15 years in Group 1 and 84 ± 7% at 10 years in Group 2. In Group 2, freedom from procedure-related reoperations was 98 ± 2% at 10 years. At last follow-up, no cases of moderate or severe aortic regurgitation were observed. Conclusions: The modified Bentall and David I procedures showed excellent early and late results. The modified Bentall procedure with a mechanical conduit was associated with thromboembolic and hemorrhagic complications, whereas the David I procedure was associated with unexplained occurrences of endocarditis. Thus, the David I procedure appears to be safe, reproducible, and capable of achieving stable aortic valve repair and is therefore our currently preferred solution for patients with annuloaortic ectasia. However, the much shorter follow-up for David I patients limits the strength of our comparison between the two techniques.

Aortic valve-sparing procedure—a durable choice in liver transplantation recipient

“…A TAVI was obviously considered contraindicated by the presence of an aortic aneurysm, but nevertheless it would have never been selected due to the young age of the patient and the still unknown durability of biological devices used for TAVI [ 9 , 10 ]; a modified Bentall procedure (MBP) with a mechanical conduit would have exposed the patient to the unjustified risks of life-long anticoagulation; finally, a MBP with a biological prosthesis would have avoided chronic anticoagulants, providing a procedure-related durability not superior to that of a valve-sparing procedure, despite an expected excellent survival after LT for HBV [ 11 ]. Indeed, our experience with aortic valve-sparing procedure has shown a 98% freedom from procedure-related reoperations at 10 years [ 1 ], while others have observed 95% freedom from reoperations on the aortic valve at 18 years [ 12 ]. Therefore, based on the previous considerations, in our patient, a valve-sparing procedure was considered the best option, combining the advantages of long-term durability and avoidance of life-long anticoagulation, which is generally contraindicated in patients with liver failure [ 13 ].…”

“…Valve-sparing procedures are currently the treatment of choice for patients with aortic regurgitation and aneurysm of root and ascending aorta, since repairing the native aortic valve combines the advantages of long-term valve durability with avoidance of anticoagulant treatment [ 1 ]. Furthermore, should a major extracardiac procedure be required during follow-up, absence of anticoagulation would minimize any potential hemorrhagic risk, especially for patients requiring solid organ transplantation such as the liver.…”

Cannulation of Innominate Artery During Proximal Aortic Aneurysm Repair

“…Reconstruction of the proximal aortic aneurysm is associated with higher mortality and morbidity rate 5 . Neurological complication is common with this procedure.…”

Transcatheter aortic valve replacement after valve‐sparing aortic root surgery

“…To the Editor, Aortic valve-sparing procedures are currently the "gold standard" approach in patients with aortic valve incompetence (AI) and aortic root dilatation. 1 Failure of valve-sparing repair requires usually surgical reoperation for recurrent AI, since the use of transcatheter aortic valve replacement (TAVR) is still considered as an "off label" procedure, regardless of its etiology. 2 In such cases, a traditional reoperation may represent a high-risk procedure, especially when a failure occurs early.…”