Aortic Root Replacement with Reimplantation of the Aortic Valve: A Low-Volume Center Experience

Abstract

Background Most data after root replacement with reimplantation of the aortic valve originate from high-volume centers. This raises concerns about the generalizability of these data and the reproducibility of this complex procedure. Aim of this study is to assess the perioperative and midterm outcomes of this procedure in a low-volume center.

Methods We performed a retrospective analysis of the data of 72 patients, who underwent root replacement with reimplantation of the aortic valve in a single center between 2011 and 2020. Time to event analysis was performed with Kaplan–Meier curves. Longitudinal analysis of serial echocardiographic data was performed with a mixed-effects ordinal logistic regression model.

Results In-hospital mortality was 1.4%, with absence of any neurological events during the perioperative period. At midterm follow-up, two further patients died. Overall survival rates at 1 and 5 years were 98.5% (95% confidence interval [CI]: 97–100%) and 96.3% (95% CI: 93.8–98.8%), respectively. During follow-up, five patients (6.9%) required reoperation on the aortic valve. The incidence of moderate and severe aortic regurgitation at 5 years was 6.6% (95% CI: 2.4–13.6%) and 0.6% (95% CI: 0.1–3.2%), respectively. Mild aortic regurgitation at hospital discharge (p < 0.001) and cusp plication (p = 0.0121) were associated with a higher incidence of moderate or severe aortic regurgitation at follow-up.

Conclusion Reimplantation of the aortic valve is safe and feasible even in a low-volume center. Mortality, freedom from reoperation, and incidence of moderate or severe aortic regurgitation at follow-up are comparable to those of high-volume centers.

Keywords

aortic valve and root - aorta/aortic - outcomes (includes mortality, morbidity)

Publication History

Received: 23 October 2020

Accepted: 29 December 2020

Article published online:
18 February 2021

• References

• 1 David TE, Feindel CM. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 1992; 103 (04) 617-621 , discussion 622
• 2 Stamou SC, Williams ML, Gunn TM, Hagberg RC, Lobdell KW, Kouchoukos NT. Aortic root surgery in the United States: a report from the Society of Thoracic Surgeons database. J Thorac Cardiovasc Surg 2015; 149 (01) 116-22.e4
• 3 Schäfers HJ. Aortic valve repair: easy and reproducible?. J Thorac Cardiovasc Surg 2015; 149 (01) 129-130
• 4 David TE, David CM, Feindel CM, Manlhiot C. Reimplantation of the aortic valve at 20 years. J Thorac Cardiovasc Surg 2017; 153 (02) 232-238
• 5 Mastrobuoni S, de Kerchove L, Navarra E. et al. Long-term experience with valve-sparing reimplantation technique for the treatment of aortic aneurysm and aortic regurgitation. J Thorac Cardiovasc Surg 2019; 158 (01) 14-23
• 6 Arabkhani B, Mookhoek A, Di Centa I. et al. Reported outcome after valve-sparing aortic root replacement for aortic root aneurysm: a systematic review and meta-analysis. Ann Thorac Surg 2015; 100 (03) 1126-1131
• 7 Kari FA, Doll KN, Hemmer W. et al. Residual and progressive aortic regurgitation after valve-sparing root replacement: a propensity-matched multi-institutional analysis in 764 patients. Ann Thorac Surg 2016; 101 (04) 1500-1506
• 8 Clark TG, Altman DG, De Stavola BL. Quantification of the completeness of follow-up. Lancet 2002; 359 (9314): 1309-1310
• 9 David TE, Armstrong S, Manlhiot C, McCrindle BW, Feindel CM. Long-term results of aortic root repair using the reimplantation technique. J Thorac Cardiovasc Surg 2013; 145 (3, suppl): S22-S25
• 10 Shrestha ML, Beckmann E, Abd Alhadi F. et al. Elective David I procedure has excellent long-term results: 20-year single-center experience. Ann Thorac Surg 2018; 105 (03) 731-738
• 11 Liebrich M, Kruszynski MK, Roser D. et al. The David procedure in different valve pathologies: a single-center experience in 236 patients. Ann Thorac Surg 2013; 95 (01) 71-76
• 12 Davies RR, Gallo A, Coady MA. et al. Novel measurement of relative aortic size predicts rupture of thoracic aortic aneurysms. Ann Thorac Surg 2006; 81 (01) 169-177
• 13 Zafar MA, Li Y, Rizzo JA. et al. Height alone, rather than body surface area, suffices for risk estimation in ascending aortic aneurysm. J Thorac Cardiovasc Surg 2018; 155 (05) 1938-1950
• 14 Baumgartner H, Falk V, Bax JJ. et al; ESC Scientific Document Group. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J 2017; 38 (36) 2739-2791
• 15 Rosenblum JM, Leshnower BG, Moon RC. et al. Durability and safety of David V valve-sparing root replacement in acute type A aortic dissection. J Thorac Cardiovasc Surg 2019; 157 (01) 14-23.e1
• 16 Beckmann E, Martens A, Krüger H. et al. Aortic valve-sparing root replacement in patients with bicuspid aortic valve: long-term outcome with the David I procedure over 20 years. Eur J Cardiothorac Surg 2020; 58 (01) 86-93
• 17 Ouzounian M, Feindel CM, Manlhiot C, David C, David TE. Valve-sparing root replacement in patients with bicuspid versus tricuspid aortic valves. J Thorac Cardiovasc Surg 2019; 158 (01) 1-9
• 18 Leontyev S, Schamberger L, Davierwala PM. et al. Early and late results after David vs Bentall procedure: a propensity matched analysis. Ann Thorac Surg 2020; 110 (01) 120-126
• 19 de Kerchove L, Boodhwani M, Glineur D. et al. Effects of preoperative aortic insufficiency on outcome after aortic valve-sparing surgery. Circulation 2009; 120 (11, suppl): S120-S126
• 20 Stephens EH, Liang DH, Kvitting JP. et al. Incidence and progression of mild aortic regurgitation after Tirone David reimplantation valve-sparing aortic root replacement. J Thorac Cardiovasc Surg 2014; 147 (01) 169-177 , 178.e1–178.e3
• 21 Schäfers HJ, Aicher D. Root remodeling for aortic root dilatation. Ann Cardiothorac Surg 2013; 2 (01) 113-116
• 22 Schäfers HJ, Aicher D, Langer F. Correction of leaflet prolapse in valve-preserving aortic replacement: pushing the limits?. Ann Thorac Surg 2002; 74 (05) S1762-S1764 , discussion S1792–S1799
• 23 Burkhart HM, Zehr KJ, Schaff HV, Daly RC, Dearani JA, Orszulak TA. Valve-preserving aortic root reconstruction: a comparison of techniques. J Heart Valve Dis 2003; 12 (01) 62-67
• 24 Tkebuchava S, Tasar R, Lehmann T. et al. Predictors of outcome for aortic valve reimplantation including the surgeon-a single-center experience. Thorac Cardiovasc Surg 2020; 68 (07) 567-574