Emmanuel Lansac

A four-dimensional study of the aortic root dynamics

OBJECTIVE Although aortic root expansion has been well studied, its deformation and physiologic relevance remain controversial. Three-dimensional (3-D) sonomicrometry (200Hz) has made time-related 4-D study possible. METHODS Fifteen sonomicrometric crystals were implanted into the aortic root of eight sheep at each base (three), commissures (three), sinuses of Valsalva (three), sinotubular junction (three), and ascending aorta (three). In this acute, open-chest model, the aortic root geometric deformations were time related to left ventricular and aortic pressures. RESULTS During the cardiac cycle, aortic root volume increased by mean+/-1 standard error of the mean (SEM) 33.7+/-2.7%, with 36.7+/-3.3% occurring prior to ejection. Expansion started during isovolumic contraction at the base and commissures followed (after a delay) by the sinotubular junction. At the same time, ascending aorta area decreased (-2.6+/-0.4%). During the first third of ejection, the aortic root reached maximal expansion followed by a slow, then late rapid decrease in volume until mid-diastole. During end-diastole, the aortic root volume re-expanded by 11.3+/-2.4%, but with different dynamics at each area level. Although the base and commissural areas re-expanded, the sinotubular junction and ascending aorta areas kept decreasing. At end-diastole, the aortic root had a truncated cone shape (base area>commissures area by 51.6+/-2.0%). During systole, the root became more cylindrical (base area>commissures area by 39.2+/-2.5%) because most of the significant changes occurred at commissural level (63.7+/-3.6%). CONCLUSION Aortic root expansion follows a precise chronology during systole and becomes more cylindrical - probably to maximize ejection. These findings might stimulate a more physiologic approach to aortic valve and aortic root surgical procedures.

Turner syndrome and pregnancy: clinical practice. Recommendations for the management of patients with Turner syndrome before and during pregnancy.

Following the death in France by acute aortic dissection of two women with Turner syndrome who were pregnant following oocyte donation, the Director of the French Biomedicine Agency (Agence de la biomédecine) sent a letter to the President of the French College of Obstetricians and Gynaecologists (FCOG). He requested the Colleges expertise in reviewing point-by-point the cases and risk factors and in determining whether there are grounds to propose additional measures complementary to the recommendations made by the Haute autorité de santé or French National Authority for Health (HAS) in 2008 in terms of indication and monitoring of patients. A joint practice committee of the FCOG, the French Cardiologic Society, the French Chest and Cardiovascular Surgery Society, the French Society of Anaesthesia and Intensive Care, the French Endocrine Society, the French study group for oocyte donation, and the Biomedicine Agency defined the exact questions to be put to the experts, chose these experts, followed them up and drafted the synthesis of recommendations resulting from their work. The questions concerned the check-up before pregnancy of Turner patients, contraindication and acceptance of pregnancy, information for the patients, and recommendations for antenatal care, delivery and postnatal follow-up.

An aortic ring: From physiologic reconstruction of the root to a standardized approach for aortic valve repair

OBJECTIVE We suggest standardizing aortic valve repair using a physiologic approach by associating root remodeling with resuspension of the cusp effective height and external subvalvular aortic ring annuloplasty. METHODS A total of 187 patients underwent remodeling associated with subvalvular aortic ring annuloplasty (14 centers, 24 surgeons). Three strategies for cusp repair were evaluated: group 1, gross visual estimation (74 patients); group 2, alignment of cusp free edges (62 patients); and group 3, 2-step approach, alignment of the cusp free edges and effective height resuspension (51 patients). The composite outcome was defined as recurrence of aortic insufficiency of grade 2 or greater and/or reoperation. RESULTS The operative mortality rate was 3.2% (n = 6). Treatment of a cusp lesion was most frequently performed in group 3 (70.6% vs 20.3% in group 1 and 30.6% in group 2, P < .001). Nine patients required reoperation during a follow-up period of 24 months (range, 12-45), 6 patients in group 1 and 3 patients in group 2. At 1 year, no patients in group 3 presented with composite outcome events compared with 28.1% in group 1 and 15% in group 2 (P < .001). Residual aortic insufficiency and tricuspid anatomy were independent risk factors for the composite outcome in groups 1 and 2. The annulus diameter, the presence of Marfan syndrome, and cusp repair had no effect on aortic insufficiency recurrence or reoperation. CONCLUSIONS A standardized and physiologic approach to aortic valve repair, considering both the aorta (root remodeling) and the valve (resuspension of the cusp effective height and subvalvular ring annuloplasty) improved the preliminary results and might affect their long-term durability. The ongoing Conservative Aortic Valve Surgery for Aortic Insufficiency and Aneurysm of the Aortic Root (CAVIAAR) trial will compare this strategy to mechanical valve replacement.

An aortic ring to standardise aortic valve repair: preliminary results of a prospective multicentric cohort of 144 patients

OBJECTIVES Multiplicity of aortic valve repair or sparing techniques results in a lack of standardisation, limiting widespread adoption of such procedures. To treat dilated diameters at the aortic annular base and sinotubular junction while maintaining root dynamics, we propose a standardised and physiological repair approach to the surgical management of aortic root aneurysms, consisting of root remodelling, cusp re-suspension and subvalvular aortic ring annuloplasty. METHODS From May 2003 to September 2009, 144 unselected patients with aortic root aneurysms underwent remodelling with external subvalvular ring annuloplasty in 13 centres (21 surgeons). Preoperative aortic insufficiency (AI) > or =grade 2 was present in 63.9% (92), Marfan syndrome in 12.5% (18) and bicuspid valve in 22.9% (33). Cusp repair was performed in 40.3% (58) patients. RESULTS Valve repair was successful in all but two cases. Repair of cusp prolapse was necessary in 58 patients, significantly more frequent in bicuspid (24/33, 72.7%) than in tricuspid (34/111, 30.6%) valves (p<0.05). Operative mortality was 2.8% (four). Subvalvular ring implantation produced a significant annular base reduction from 27.6+/-2.5 mm to 20.5+/-2.6 mm (p<0.01) without significant mean trans-valvular gradient (7.2+/-1.7 mmHg). During follow-up (median 2.2 years (0.75-4.4, maximum 6.25 years)), five patients died while eight required a re-operation. Six were operated on during our early experience. Strategy for cusp re-suspension evolved over three operative periods, with a significant increase in the rate of cusp repair. From May 2003 to December 2006: eye balling evaluation (15/67 (22.4%)); from January 2007 to August 2008: alignment of cusp free edges (17/38 (44.7%)); and from September 2008 to September 2009: a two-step standardised repair consisting of alignment of cusp free edges and effective height re-suspension (26/39 (66.7%) p<0.05). Freedom from AI> or =grade 2 was 91.3% (115) at the end of follow-up. CONCLUSIONS Implantation of an external aortic ring provides a reproducible technique for aortic valve repair with satisfactory preliminary results. The ongoing CAVIAAR trial (Conservative Aortic Valve surgery for aortic Insufficiency and Aneurysm of the Aortic Root) will compare this standardised repair technique using an expansible aortic ring to mechanical valve replacement.

A lesional classification to standardize surgical management of aortic insufficiency towards valve repair

OBJECTIVE Aortic valve repair is an alternative to valve replacement for treatment of chronic aortic insufficiency (AI). In order to standardize surgical management, we suggest a classification based on echocardiographic and operative analysis of valvular lesions. METHODS Classification was based on the retrospective analysis of chronic AI mechanisms of 781 adults operated on electively between 1997 and 2003. RESULTS AI was isolated (406 patients (52%)), associated with supra-coronary aneurysm (97 cases (12.4%)), or with aortic root aneurysm (278 patients (35.6%)). Etiologies of valvular or aortic lesions were respectively rheumatic, dystrophic and atheromatous in 17%, 73.6% and 9.4% of cases. Lesional classification is based on the analysis of chronic AI mechanisms defining type I with central jet (354 cases, 45.3%) and type II with eccentric jet (54.7%). Type Ia is defined as isolated dilation of sino-tubular junction (47 supra-coronary aneurysms), and type Ib as dilation of both sino-tubular junction and aortic annular base (233 root aneurysms, 74 isolated AI). The type II associates dilation of sino-tubular junction and annular base to a valvular lesion: IIa cusp prolapse (95 aneurysms, 200 isolated AI); IIb cusp retraction (132 rheumatic AI), IIc cusp tear (endocarditis, traumatic). CONCLUSION A lesional classification aims to standardize the surgical management of aortic valve repair: type Ia, by supra-coronary graft; type Ib, by subvalvular aortic annuloplasty associated with the aortic root replacement with a remodelling technique (root aneurysm) or double sub- and supravalvular annuloplasty (isolated AI). For chronic AI type II, aortic annuloplasty associated a remodelling technique or double sub- and supravalvular annuloplasty is combined with the treatment of the cusp lesion (cusp resuspension, cusp reconstruction with autologous pericardium).

Reported Outcome After Valve-Sparing Aortic Root Replacement for Aortic Root Aneurysm: A Systematic Review and Meta-Analysis

Valve-sparing aortic root techniques have progressively gained ground in the treatment of aortic root aneurysm and aortic insufficiency. By avoiding anticoagulation therapy they offer a good alternative to composite graft replacement. This systematic review describes the reported outcome of valve-sparing aortic root replacement, focusing on the remodeling and reimplantation technique. A systematic literature search on the characteristics of and outcomes after valve-sparing aortic root replacement revealed 1,659 articles. The inclusion criteria were a focus on valve-sparing aortic root replacement in adults with aortic root aneurysm, presentation of survival data, and inclusion of at least 30 patients. Data were pooled by inverse variance weighting and analyzed by linear regression. Of 1,659 articles published between January 1, 2000, and January 1, 2014, 31 were included (n = 4,777 patients). The mean age at operation was 51 ± 14.7 years, and 14% of patients had a bicuspid aortic valve. The reimplantation technique was used in 72% and remodeling in 27% (1% other). No clinical advantage in terms of survival and reoperation of one technique over the other was found. Cusp repair was performed in 33%. Pooled early mortality was 2% (n = 103). During follow-up (21,716 patient-years), 262 patients died (survival 92%), and 228 (5%) underwent reoperation, mainly valve replacement. Major adverse valve-related events were low (1.66% patient-years). Preoperative severe aortic valve regurgitation showed a trend toward higher reoperation rate. Remodeling and reimplantation techniques show comparable survival and valve durability results, providing a valid alternative to composite valve replacement. The heterogeneity in the data underlines the need for a collaborative effort to standardize outcome reporting.

Dilation of the thoracic aorta: medical and surgical management

Dilation of the ascending aorta entails a high risk of dissection or aortic rupture in the absence of surgical treatment. Overall, it represents 50% of all thoracic aneurysms, but can be separated into two distinct entities, according to aetiology and surgical management: (1) the aortic root aneurysm, concerning the initial portion, the so called “aortic root”, that includes the sinuses of Valsalva; and (2) the “supravalvular aortic aneurysms” above the sinuses of Valsalva up the brachiocephalic trunk (fig 1). In contrast to the supravalvular aneurysm that can be treated by a simple supracoronary tube graft, the aortic root aneurysm involves the aortic valve which needs to be spared or replaced. Recent surgical advances have been developed for aortic root aneurysms, which are detailed in this report. Figure 1  Normal ascending aorta: aortic root, sinotubular junction, and supravalvular aorta. Aortic aneurysms remain the 13th leading cause of mortality in western countries.1,2 The incidence of thoracic aortic aneurysms is estimated to be 4.5 cases per 100 000.1–3 Supravalvular aortic aneurysms are less common, and predominantly affect male patients (ratio 3:1); the mean age at the time of diagnosis ranges from 59–69 years.3 In the case of aortic root aneurysms, patients are younger (30–50 years), with a 1:1 sex ratio. Supravalvular aortic aneurysms are caused by atherosclerosis in relation to hypertension, whereas aneurysm of the aortic root is related to dystrophic degeneration of the aortic wall—so called cystic medial necrosis.1,3 Aneurysm of the aortic root (annulo-aortic ectasia) can be either idiopathic or associated with well-defined connective tissue disorders such as Marfan syndrome, Ehler Danlos syndrome, or bicuspid valve1,3 (figs 2 and 3). Figure 2  Supravalvular aortic aneurysm. Figure 3  Aortic root aneurysm. Twenty per cent of patients with Marfan syndrome (autosomal dominant connective tissue disorder, incidence 2/5000) will be operated …

An expansible aortic ring to preserve aortic root dynamics after aortic valve repair

OBJECTIVES Aortic annuloplasty and preservation of root dynamics have been described as factors for durability of aortic valve repair. The objective of this study is to document the first clinical analysis of root dynamics after a standardized valve-sparing procedure for root aneurysms associating a calibrated expansible external aortic ring annuloplasty with a physiological remodelling of the aortic root (CAVIAAR technique: Conservative Aortic Valve surgery for aortic Insufficiency and Aneurysm of the Aortic Root). METHODS Of the 600 patients operated on with the CAVIAAR technique, 60 consecutive patients from a single team underwent double independent reading of the echocardiographic analysis performed in the operative period and yearly after discharge until a maximum of 5-year follow-up. Forty-four patients had preoperative aortic insufficiency (AI) ≥grade 2 (73.3%) and 29 patients (48%) had bicuspid valves. RESULTS The expansible aortic ring (median size 27 (25-27) mm) significantly reduced the aortic annular base diameter (from 28 (25-29) mm to 23 (21-24) mm) (P < 0.001) without a significant median transvalvular gradient increase (P = 0.545). Cusp repair was performed in 55 patients (91.7%). Operative mortality was 1.7% (1). During the median 19-month (95% confidential interval [11-26]) follow-up, annular diameter and cusp effective height remained stable. There were no valve-related reoperations. One patient died at 6 months postoperatively from congestive heart failure. Freedom from AI ≥grade 2 was 100% at 1-year follow-up and 96.8% ± 3.2% at 3-year follow-up. Systolic root expansibility of the four echocardiographic diameters (aortic annular base, sinuses of Valsalva level, sino tubular junction and tubular aorta) was maintained, throughout the follow-up period with the aortic annular base expansibility coefficient having consistently higher values than the three other levels. CONCLUSIONS The expansible aortic ring achieved a complete calibrated external annuloplasty and maintained dynamics of the aortic root at mid-term follow-up. Whether this could be a factor for durability of aortic valve repair is currently under evaluation through the CAVIAAR study 10-year follow-up.

Remodeling root repair with an external aortic ring annuloplasty

Objective: Although the remodeling technique provides the most dynamic valve‐sparing root replacement, a dilated annulus (>25 mm) is a risk factor for failure. Aortic annuloplasty aims to reduce the annulus diameter, thus increasing coaptation height to protect the repair. The results of 177 patients with remodeling and external aortic ring annuloplasty were studied. Methods: Data were collected from the Aortic Valve repair InternATiOnal Registry. Preoperative aortic insufficiency grade 3 or greater was present in 79 patients (44.7%). The valve was bicuspid in 59 patients (33.3%). External annuloplasty was performed through a homemade Dacron ring (56) or a dedicated expansible aortic ring (121). Results: Thirty‐day mortality was 2.9% (5). Mean follow‐up was 41.1 ± 36.4 months. For the whole series, freedom from valve‐related reoperation, aortic insufficiency grade 3 or greater, aortic insufficiency grade 2 or greater, and major adverse valve‐related events were 89.5%, 90.5%, 77.4%, and 86.6% at 7 years, respectively, with similar results for tricuspid and bicuspid valves. Since 2007, systematic use of calibrated expansible ring annuloplasty, followed 1 year later by systematic cusp effective height assessment, significantly increased 7‐year freedom from valve‐related reoperation, aortic insufficiency grade 3 or greater, and major adverse valve‐related events up to 99.1% ± 0.9% (P = .017), 100% (P = .026), and 96.3% ± 1.8% (P = .035), respectively, whereas freedom from aortic insufficiency grade 2 or greater remained unaffected (78.1% ± 7.6%). Calibrated annuloplasty and effective height assessment were identified as protective factors from reoperation: hazard ratio, 0.13; 95% confidence interval, 0.02‐1.06; P = .057 and hazard ratio, 0.11; 95% confidence interval, 0.01‐0.95; P = .044, respectively. Conclusions: The standardization of remodeling root repair with calibrated expansible aortic ring annuloplasty and cusp effective height assessment improves valve repair outcomes.

Long-term results of external aortic ring annuloplasty for aortic valve repair.

OBJECTIVES An untreated dilated aortic annulus is a major risk factor for failure of aortic valve-sparing operations or repair of either bicuspid or tricuspid valve. Aortic annuloplasty efficiently reduces the annulus and increases the coaptation height, thus protecting the repair. This study analyses long-term results of 232 consecutive patients operated on with a standardized and physiological approach to aortic valve repair according to each phenotype of the dystrophic ascending aorta. Subvalvular aortic annuloplasty was systematically added using an external aortic ring to reduce annulus diameter when ≥25 mm. METHODS Data were collected into the multicentric international AVIATOR registry (AorticValve repair InternATiOnal Registry): 149 patients with root aneurysm underwent remodelling with an external ring; 21 patients with tubular aortic aneurysm underwent supracoronary grafts with an external open ring and 62 patients with isolated aortic insufficiency (AI) underwent double sub- and/or supravalvular external open ring annuloplasty. Preoperative AI ≥ Grade III was present in 58.6% (133), and the valve was bicuspid in 37.9% (88). RESULTS Cusp repair was performed in 75.4% (175) patients. The 30-day operative mortality rate was 1.4% (3). The mean follow-up was 40.1 ± 37.8 months (0-145.5). The actuarial survival rate at 7 years was 89.9%. The rate of freedom from reoperation at 7 years was similar among each phenotype, being 90.5% for root aneurysms, 100% for tubular aortic aneurysms and 97.5% for isolated AI with no difference between the bicuspid and tricuspid valve. The rates of freedom from AI ≥ Grade 2 and from AI ≥ Grade 3 at 7 years were, respectively, 76.0 and 93.1% for root aneurysms, 92.9 and 100% for tubular aortic aneurysms and 57.3 and 82.2% for isolated AI. Eye balling repair achieved suboptimal valve competency when compared with systematic cusp effective height assessment, which tended to improve the rate freedom from reoperation, respectively, from 85.8 ± 5.5% to 98.9 ± 1.1% and the rate of freedom from AI ≥ Grade 3 from 89.8 ± 4.9% to 100%. For isolated AI, an additional sinotubular junction ring (double sub- and supravalvular annuloplasty) tended to reduce recurrent AI when compared with single subvalvular annuloplasty. CONCLUSIONS External aortic ring annuloplasty provides a reproducible technique for aortic valve repair with satisfactory long-term results for each ascending aorta phenotype with bicuspid or tricuspid valve. Longer follow-up is ongoing with the AVIATOR registry.