Caroline Komlo

Root Stabilization of the Repaired Bicuspid Aortic Valve: Subcommissural Annuloplasty Versus Root Reimplantation

BACKGROUND At our institution, type I bicuspid aortic valve (BAV) patients with aortic insufficiency (AI) who are candidates for valve preservation are stratified into two groups by aortic root pathology: nonaneurysmal root undergoing primary cusp repair+subcommissural annuloplasty (repair group) vs aneurysmal root undergoing primary cusp repair+root reimplantation (reimplantation group). We report outcomes of this surgical reconstructive strategy for the repaired type I BAV. METHODS A retrospective review was performed of 71 patients with a type I BAV undergoing primary valve repair from 2005 to 2012. The repair group (n=40) underwent annular stabilization by subcommissural annuloplasty, and the reimplantation group (n=31) underwent robust annular stabilization provided by root reimplantation. RESULTS Preoperative characteristics and root anatomy were similar, except for increased root dimensions in the reimplantation group (p<0.001). Mortality, stroke, valve reoperation, and pacemaker requirement were zero in both groups. Postoperative peak (19±10 vs 11±5 mm Hg, p<0.001) and mean gradients (10±5 vs 5±3 mm Hg, p<0.001) favored root reimplantation. Freedom from AI greater than 1+ was 100% in both groups. Mean follow-up was 40 months in the reimplantation group and 38 months in the repair group. At 5 years, overall survival was 100% in both groups. Freedom from aortic reoperation and AI exceeding 2+ were similar in both groups. Freedom from AI exceeding 1+ was significantly better in the reimplantation group (92%±6% vs 62%±10%, p=0.03). The 2-year peak (14±6 vs 19±9 mm Hg, p=0.009) and mean (7±4 vs 11±5 mm Hg, p=0.001) gradients favored root reimplantation. CONCLUSIONS Root stabilization with the reimplantation technique significantly improves the durability of the repaired type I BAV compared with subcommissural annuloplasty. It also provides improved and sustained valve mobility (transvalvular gradients).

Moderate Versus Deep Hypothermic Circulatory Arrest for Elective Aortic Transverse Hemiarch Reconstruction

BACKGROUND Deep hypothermic circulatory arrest (DHCA) with retrograde cerebral perfusion (DHCA group) has traditionally been the cerebral protection strategy during transverse hemiarch aortic reconstruction. Recently, we have adopted moderate hypothermic (≥ 25 °C) circulatory arrest (MHCA) with antegrade cerebral perfusion (MHCA group). We compared the outcomes for these two circulatory arrest management strategies. METHODS From 2008 to 2012, in a concurrent series of 376 patients (DHCA, 301; MHCA, 75) undergoing transverse hemiarch for aortic aneurysm disease, incidences of concomitant root replacement (44% vs 47%, p = 0.8), and aortic valve replacement (29% vs 21%, p = 0.3) were similar, although atherosclerotic aneurysm pathology was present in patients in the MHCA group (71% vs 33%, p < 0.01). Antegrade cerebral perfusion was established via axillary artery or direct innominate artery cannulation. A database was prospectively maintained. RESULTS MHCA group patients were older (66 ± 11 vs 60 ± 14 years; p < 0.01). Other demographics were similar. Aortic cross-clamp (128 ± 46 vs 163 ± 57 minutes, p < 0.01) and cardiopulmonary bypass (167 ± 49 vs 222 ± 61 minutes, p < 0.01) times were lower in the MHCA group. Transfusion requirements were significantly reduced with MHCA (38% vs 61%, p < 0.01), especially use of fresh frozen plasma and cryoprecipitate. Direct innominate artery cannulation did not result in any vascular or neurologic complication. Postoperative outcomes were similar. In-hospital and 30-day mortality was 1% in both groups. Stroke (0% vs 2%) and hemodialysis rates (0% vs 1%) were also similar. CONCLUSIONS MHCA with antegrade cerebral perfusion yields excellent and equivalent outcomes to DHCA for elective aortic hemiarch reconstruction. MHCA significantly improves intraoperative times and, importantly, reduces transfusion requirements compared with DHCA with a retrograde cerebral perfusion strategy.

Combined heart-liver transplant in a situs-ambiguous patient with failed Fontan physiology.

Combined heart–liver transplantation (CHLT) in patients with congenital heart disease (CHD) has been performed in the setting of heart–liver failure secondary to failed Fontan/single-ventricle physiology. Recently, referral of patients with failed Fontan physiology has increased at our institution. These patients now present—15 to 20 years post-Fontan palliation—with a ‘‘burned out’’singleventricle with ensuing liver failure.CHLTin these patients is challenging with regard to intraoperative techniques and postoperative care. CHLT in patients with situs inversus/ambiguous can be evenmore complex, requiring technicalmodifications and complex venous and arterial reconstruction.

Two-stage surgical strategy for aortoesophageal fistula: emergent thoracic endovascular aortic repair followed by definitive open aortic and esophageal reconstruction.

DISCUSSION PV stenosis appears frequently in neonates or infants with congenital heart disease such as total anomalous pulmonary venous connection. PV stenosis can be repaired using several surgical procedures, including a sutureless technique, patchplasty, excision of the stenosis, and reimplantation of the PV with direct anastomosis. The sutureless technique has evolved as a method to treat patients with recurrent PV stenosis developing after repair of total anomalous pulmonary venous connection. This technique requires no direct suturing of the PVs, enabling aggressive resection of the anterior wall of the segmental PV. Thus, the PV confluence can be created as wide as possible, even in complicated cases such as redo procedures. Additionally, oblique incision of the LAAp is key to creating a large atriopericardial anastomosis. Although various congenital cases have been documented, to the best of our knowledge, only 1 adult case has been previously reported. In a 43-year-old man with PV stenosis caused by idiopathic mediastinal fibrosis, pericardial patchplasty was performed for repair. After that report, we used conventional patchplasty for the first time. Subsequently, the sutureless technique was indicated for recurrent PV stenosis. However, a recent study reported that no significant difference could be found in the primary outcomes between the primary sutureless technique and conventional patchplasty in patients with a total anomalous pulmonary venous connection. Accordingly, our strategy was considered reasonable and proper for the present patient. Currently, more than 40,000 cases of catheter ablation are attempted each year in the United States. PV stenosis induced by ablation occurs in 1% to 3% of patients, and

Geometric orientation of the aortic neoroot in patients with raphed bicuspid aortic valve disease undergoing primary cusp repair and a root reimplantation procedure

OBJECTIVES Primary cusp repair + aortic root reimplantation in bicuspid aortic valve (BAV) disease presenting with root aneurysm with aortic insufficiency (AI) is an effective surgical treatment. We assessed whether the geometric orientation of the repaired BAV into its reimplanted neoroot affects outcomes-180°/180° orientation was compared with the 150°/210° orientation. METHODS From 2005 to 2012, 66 BAV repairs were performed. This is a retrospective review of all types of Ib/II BAV AI patients undergoing root reimplantation (n = 26) at two different geometric orientations: 180°/180° (n = 11) vs 150°/210° (n = 15). In the 180°/180° group, reimplantation into the neoroot was such that both conjoint and non-conjoint cusps occupied 180° of the annular circumference. In the 150°/210° group, the repaired valve was configured to the more typical native orientation of a type I BAV: the non-conjoint cusp occupied 150°, and the conjoint cusp occupied 210° of the annular circumference. RESULTS Preoperative characteristics were similar in both groups. In-hospital mortality, stroke, reoperation, renal failure and pacemaker rates were zero in both groups. No patient left the operating room with >1+ AI and one had a peak gradient >20 mmHg. Transvalvular gradients were higher in the 180°/180° group, but not significant (P > 0.05). M.ean follow-ups for the 180°/180° and 150°/210° group were 48 and 33 months, respectively. Actuarial freedom from AI >2+ at 5 years was 100% in both groups. Freedom from AI >1+ at 5 years was 90 ± 10% in the 150°/210° group and 86 ± 13% in the 180°/180° group (P = 0.71). Freedom from peak gradient >20 mmHg was 80% (n = 8) in the 180°/180° group and 100% in the 150°/210° group at 1-year follow-up. Transvalvular gradients were higher in the 180°/180° group (16 ± 8 vs 10 ± 4 mmHg, P = 0.02; 9 ± 3 vs 5 ± 3 mmHg, P = 0.01). Five-year actuarial survival and freedom from aortic reoperation have remained at 100% in the entire cohort. CONCLUSION Cusp repair + root reimplantation for BAV type Ib/II AI can be safely performed at either geometric orientation. Conceptually, 150°/210° orientation respects the natural type I BAV anatomy with regard to cusp surface area and leaflet insertion perimeter. The 180°/180° group may have higher transvalvular gradients and smaller coaptation zones than the 150°/210° group. Further follow-up may reveal the superiority of one geometric orientation over the other.

Type II arch hybrid debranching procedure

Management of aortic arch aneurysm and dissection continues to evolve as endovascular options play an increasing role in treating thoracic aortopathies. Although conventional open treatment of aortic arch disease with total arch replacement still remains the gold standard, in patients with old age and/or high comorbid disease index, there is significant associated morbidity and mortality. The hybrid arch procedure, which aims to minimize cardiopulmonary bypass and circulatory arrest times, is a particularly appealing surgical option in this cohort of patients. The hybrid arch concept essentially entails three main principles: (I) open debranching of the great vessels; (II) creation of proper proximal (zone 0 landing) and distal landing zones, and; (III) concomitant or delayed endovascular stent grafting of the aortic arch. The classification scheme for hybrid arch debranching procedures is based on the extent of proximal and distal landing zone reconstruction required, and thus the need and extent of cardiopulmonary bypass and circulatory arrest management strategies to be employed. In this illustrated article, we describe the details of the type II hybrid arch debranching procedure, where the ascending aorta and aortic arch pathology is typically treated by reconstruction of ascending aorta ﹢ arch vessel debranching, with concomitant antegrade stent grafting of the aortic arch.

How I Teach a Valve-Sparing Root Replacement

The historic operation of choice for patients with sinus of Valsalva aneurysms is a Bentall operation, which involves replacement of the aortic valve and sinus segment with reimplantation of the coronary arteries. This operation has proven excellent long-term results [1]. However, in a select group of patients who have repairable or normal aortic valves with a sinus of Valsalva aneurysm, a valve-sparing root replacement (VSRR) is an appealing alternative. The ability to preserve a patient’s valve, obviating the need for anticoagulation therapy, makes it attractive because the disease tends to affect young patients who would otherwise need mechanical valves. The two most common procedures to address the pathology include the root remodeling technique by Magdi Yacoub and the reimplantation technique described by Tirone David and Christopher Feindel [2]. We prefer the latter in most patients because the operation has the added benefit of stabilizing the annulus. Teaching the VSRR operation is something we have done for more than a decade. It requires familiarity and mastery of the operation as the attending surgeon in addition to patience and the ability to teach, understand, and perform the operation from the “left side of the table.” Moreover, not all VSRRs are the same. Teaching a VSRR operation in a patient with normal left ventricular function and no aortic insufficiency (AI) is clearly not the same as teaching a VSRR operation in a patient with eccentric trileaflet AI with abnormal left ventricular function. For the sake of simplicity, we will describe how we teach a VSRR procedure in a trileaflet valve without any leaflet pathology.

Echocardiographic determinants of LV functional improvement after transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) is an established therapy in high‐risk patients with severe aortic stenosis. Among patients with reduced left ventricular ejection fraction (LVEF), it is unclear which patients will derive maximal benefit from TAVR.

Valve-sparing aortic root reimplantation and cusp repair in bicuspid aortic valve: with aortic insufficiency and root aneurysm.

The text of this manuscript describes the surgical techniques demonstrated in our video, “Valve-sparing aortic root reimplantation in bicuspid aortic valve: with aortic insufficiency (AI) and root aneurysm” (Video 1). Video 1 Valve-sparing aortic root reimplantation and cusp repair in bicuspid aortic valve: with aortic insufficiency and root aneurysm This video shows our approach to valve-sparing aortic root reimplantation in bicuspid aortic valve (BAV) presenting with proximal dilation and eccentric aortic valve insufficiency. Understanding the aortic insufficiency classification system as conceived by the Brussels group under the direction of Gebrine El Khoury and published by Boodhwani et al. is important. This video is our approach to the combination type Ib/II BAV. This is the most common presentation and represents aortic root dilation with cusp prolapse. The anatomy of the classically repairable type Ib/II BAV is characterized by lack of signification leaflet calcification, presence of eccentric AI, and dilated proximal aorta with sinotubular junction (STJ) effacement. Note that the actual sinus segment is mildly dilated only. The main concepts of bicuspid aortic valve repair and root reimplantation are as follows: (I) leaflet/cusp free margin equalization, (II) annular stabilization and annular reduction, (III) raphe release (IV) optimization of the leaflet coaptation height to ensure elevation of this height above the annular plane, and (V) root reimplantation and coronary button reconstruction.

Central cannulation strategy for extent I thoracoabdominal aneurysm repair of chronic type B aortic dissection

We evaluated the safety profile of a central cardiopulmonary bypass (CPB) cannulation strategy for repair of extent I thoracoabdominal aortic aneurysms (TAAA) with chronic type B dissection in comparison to traditional peripheral CPB cannulation strategies.