CC BY-NC-ND 4.0 · Aorta (Stamford) 2023; 11(01): 029-035
DOI: 10.1055/s-0042-1757949
State-of-the-Art Review

Aortic Root Surgery in Adults: An Unsolved Problem

Carlotta Brega 
1   Department of Cardiovascular Surgery, GVM Care and Research, Cotignola, RA, Italy
,
Alberto Albertini
1   Department of Cardiovascular Surgery, GVM Care and Research, Cotignola, RA, Italy
› Author Affiliations Funding None.
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Abstract

Nowadays, despite the rapid advancements in interventional cardiology, open surgery still deals with aortic root diseases, to assure the best “ad hoc” treatment. In case of middle-aged adult patients, the optimal operation still represents a matter of debate. A review of the last 10-year literature was conducted, focusing on patients below 65 to 70 years of age. Because of the small sample and the heterogeneity of the papers, no metanalysis was possible. Bentall–de Bono procedure, valve sparing, and Ross operations are the surgical options currently available. The main issues in the Bentall – de Bono operation are lifelong anticoagulation therapy and cavitation in case of mechanical prosthesis implantation and structural valve degeneration in case of biological Bentall. As transcatheter procedures are currently performed as valve in valve, biological prosthesis may be preferable, if the diameter may prevent postoperative high gradients. Conservative techniques, such as remodeling and reimplantation, preferred in the young, guarantee physiologic aortic root dynamics and impose surgical analysis of the aortic root structures to get a durable result. The Ross operation, which shows excellent performance, involves autologous pulmonary valve implantation and is performed only in experienced and high-volume centers. Due to its technical difficulty, it requires a steep learning curve and presents some limitations in specific aortic valve diseases. All three have advantages and downsides, and no ideal solution has still been reported.

Keywords

aortic root - aortic root surgery - Bentall's procedure - valve-sparing operations - Ross' operation


Publication History

Received: 15 November 2021

Accepted: 08 August 2022

Article published online:
27 February 2023

© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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  • References

  • 1 Ozaki S, Kawase I, Yamashita H, Uchida S, Takatoh M, Kiyohara N. Midterm outcomes after aortic valve neocuspidization with glutaraldehyde-treated autologous pericardium. J Thorac Cardiovasc Surg 2018; 155 (06) 2379-2387
    CrossrefPubMedGoogle Scholar
  • 2 Seese L, Yoon P, Morell VO, Chu D. Aortic root replacement with autologous pericardium valved conduit. Ann Thorac Surg 2022; 113 (03) e227-e229
    CrossrefPubMedGoogle Scholar
  • 3 Otto CM, Nishimura RA, Bonow RO. et al; Writing Committee Members. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 77 (04) e25-e197
    CrossrefPubMedGoogle Scholar
  • 4 Loewen P, Dahri K. Risk of bleeding with oral anticoagulants: an updated systematic review and performance analysis of clinical prediction rules. Ann Hematol 2011; 90 (10) 1191-1200
    CrossrefPubMedGoogle Scholar
  • 5 Vriz O, Arshi F, Ahmed M. et al. Cavitation phenomenon in mechanical prosthetic valves: not only microbubbles. Echocardiography 2020; 37 (06) 876-882
    CrossrefPubMedGoogle Scholar
  • 6 Rahimtoola SH. Choice of prosthetic heart valve in adults an update. J Am Coll Cardiol 2010; 55 (22) 2413-2426
    CrossrefPubMedGoogle Scholar
  • 7 Puskas JD, Gerdisch M, Nichols D. et al; PROACT Investigators. Anticoagulation and antiplatelet strategies after On-X mechanical aortic valve replacement. J Am Coll Cardiol 2018; 71 (24) 2717-2726
    CrossrefPubMedGoogle Scholar
  • 8 Desai ND, McCarthy F, Moser W. et al. Durability of porcine bioroots in younger patients with aortic root pathology: a propensity-matched comparison with composite mechanical roots. Ann Thorac Surg 2011; 92 (06) 2054-2060 , discussion 2060–2061
    CrossrefPubMedGoogle Scholar
  • 9 Pantaleo A, Murana G, Di Marco L. et al. Biological versus mechanical Bentall procedure for aortic root replacement: a propensity score analysis of a consecutive series of 1112 patients. Eur J Cardiothorac Surg 2017; 52 (01) 143-149
    CrossrefPubMedGoogle Scholar
  • 10 Di Marco L, Pacini D, Pantaleo A. et al. Composite valve graft implantation for the treatment of aortic valve and root disease: results in 1045 patients. J Thorac Cardiovasc Surg 2016; 152 (04) 1041-1048 .e1
    CrossrefPubMedGoogle Scholar
  • 11 Castrovinci S, Tian DH, Murana G. et al. Aortic root replacement with biological valved conduits. Ann Thorac Surg 2015; 100 (01) 337-353
    CrossrefPubMedGoogle Scholar
  • 12 De Paulis R, Scaffa R, Salica A, Weltert L, Chirichilli I. Biological solutions to aortic root replacement: valve-sparing versus bioprosthetic conduit. J Vis Surg 2018; 4: 94
    CrossrefPubMedGoogle Scholar
  • 13 Galiñanes M, Meduoye A, Ferreira I, Sosnowski A. Totally biological composite aortic stentless valved conduit for aortic root replacement: 10-year experience. J Cardiothorac Surg 2011; 6: 86
    CrossrefPubMedGoogle Scholar
  • 14 Dougenis D, Daily BB, Kouchoukos NT. Reoperations on the aortic root and ascending aorta. Ann Thorac Surg 1997; 64 (04) 986-992
    CrossrefPubMedGoogle Scholar
  • 15 Fukunaga N, Koyama T, Konishi Y, Murashita T, Okada Y. Clinical outcome of redo operation on aortic root. Gen Thorac Cardiovasc Surg 2014; 62 pages 215-220
    CrossrefPubMedGoogle Scholar
  • 16 Albertini A, Dell'Amore A, Zussa C, Lamarra M. Modified Bentall operation: the double sewing ring technique. Eur J Cardiothorac Surg 2007; 32 (05) 804-806
    CrossrefPubMedGoogle Scholar
  • 17 Rodés-Cabau J, Dumont E, Doyle D, Lemieux J. Transcatheter valve-in-valve implantation for the treatment of stentless aortic valve dysfunction. J Thorac Cardiovasc Surg 2010; 140 (01) 246-248
    CrossrefPubMedGoogle Scholar
  • 18 Ferrari E, Marcucci C, Sulzer C, von Segesser LK. Which available transapical transcatheter valve fits into degenerated aortic bioprostheses?. Interact Cardiovasc Thorac Surg 2010; 11 (01) 83-85
    CrossrefPubMedGoogle Scholar
  • 19 Ye J, Webb JG, Cheung A. et al. Transapical transcatheter aortic valve-in-valve implantation: clinical and hemodynamic outcomes beyond 2 years. Thorac Cardiovasc Surg 2013; 145 (06) 1554-1562
    CrossrefPubMedGoogle Scholar
  • 20 Durko AP, Head SJ, Pibarot P. et al. Characteristics of surgical prosthetic heart valves and problems around labelling: a document from the European Association for Cardio-Thoracic Surgery (EACTS)-The Society of Thoracic Surgeons (STS)-American Association for Thoracic Surgery (AATS) Valve Labelling Task Force. Eur J Cardiothorac Surg 2019; 55 (06) 1025-1036
    CrossrefPubMedGoogle Scholar
  • 21 Lopez S, Meyer P, Teboul J. et al. Transcatheter valve-in-valve implantation in a degenerated very small Mitroflow prosthesis. Interact Cardiovasc Thorac Surg 2018; 27 (06) 850-855
    CrossrefPubMedGoogle Scholar
  • 22 Lansac E, Di Centa I, Sleilaty G. et al. Remodeling root repair with an external aortic ring annuloplasty. J Thorac Cardiovasc Surg 2017; 153 (05) 1033-1042
    CrossrefPubMedGoogle Scholar
  • 23 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
    CrossrefPubMedGoogle Scholar
  • 24 Lee H, Cho YH, Sung K. et al. Clinical outcomes of root reimplantation and Bentall procedure: propensity score matching analysis. Ann Thorac Surg 2018; 106 (02) 539-547
    CrossrefPubMedGoogle Scholar
  • 25 Ouzounian M, Rao V, Manlhiot C. et al. Valve-sparing root replacement compared with composite valve graft procedures in patients with aortic root dilation. J Am Coll Cardiol 2016; 68 (17) 1838-1847
    CrossrefPubMedGoogle Scholar
  • 26 Badiu CC, Deutsch MA, Sideris C. et al. Aortic root replacement: comparison of clinical outcome between different surgical techniques. Eur J Cardiothorac Surg 2014; 46 (04) 685-692 , discussion 692
    CrossrefPubMedGoogle Scholar
  • 27 Gaudino M, Lau C, Munjal M, Avgerinos D, Girardi LN. Contemporary outcomes of surgery for aortic root aneurysms: a propensity-matched comparison of valve-sparing and composite valve graft replacement. J Thorac Cardiovasc Surg 2015; 150 (05) 1120-9 .e1
    CrossrefPubMedGoogle Scholar
  • 28 Dinato FJ, Dias RR, Duncan JA. et al. Brazilian single-center experience with aortic root replacement in 448 patients: what is the best technique?. Rev Bras Cir Cardiovasc 2020; 35 (06) 869-877
    CrossrefPubMedGoogle Scholar
  • 29 Miyahara S, Matsueda T, Izawa N. et al. Mid-term results of valve-sparing aortic root replacement in patients with expanded indications. Ann Thorac Surg 2015; 100 (03) 845-851 , discussion 852
    CrossrefPubMedGoogle Scholar
  • 30 Kari FA, Liang DH, Kvitting JP. et al. Tirone David valve-sparing aortic root replacement and cusp repair for bicuspid aortic valve disease. J Thorac Cardiovasc Surg 2013;145(3, suppl):S35–40.e1, 2
    PubMedGoogle Scholar
  • 31 Patel PM, Wei JW, McPherson L, Binongo J, Leshnower BG, Chen EP. Bicuspid aortic valve sparing root replacement. J Card Surg 2021; 36 (01) 118-123
    CrossrefPubMedGoogle Scholar
  • 32 Kari FA, Doll KN, Hemmer W. et al. Survival and freedom from aortic valve-related reoperation after valve-sparing aortic root replacement in 1015 patients. Interact Cardiovasc Thorac Surg 2016; 22 (04) 431-438
    CrossrefPubMedGoogle Scholar
  • 33 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
    CrossrefPubMedGoogle Scholar
  • 34 Kvidal P, Bergström R, Hörte LG, Ståhle E. Observed and relative survival after aortic valve replacement. J Am Coll Cardiol 2000; 35 (03) 747-756
    CrossrefPubMedGoogle Scholar
  • 35 Bouhout I, Stevens LM, Mazine A. et al. Long-term outcomes after elective isolated mechanical aortic valve replacement in young adults. J Thorac Cardiovasc Surg 2014; 148 (04) 1341-1346 .e1
    CrossrefPubMedGoogle Scholar
  • 36 Mihaljevic T, Nowicki ER, Rajeswaran J. et al. Survival after valve replacement for aortic stenosis: implications for decision making. J Thorac Cardiovasc Surg 2008; 135 (06) 1270-1278 , discussion 1278–1279
    CrossrefPubMedGoogle Scholar
  • 37 Fok M, Shaw M, Sancho E, Abello D, Bashir M. Aortic valve repair: a systematic review and meta-analysis of published literature. Aorta (Stamford) 2014; 2 (01) 10-21
    Article in Thieme ConnectPubMedGoogle Scholar
  • 38 El-Hamamsy I, Warnes C, Nishimura RA. The Ross procedure in adults: the ideal aortic valve substitute?. JACC 2021; 77 (11) 1423-1425
    CrossrefPubMedGoogle Scholar
  • 39 Ross DN. Replacement of aortic and mitral valves with a pulmonary autograft. Lancet 1967; 2 (7523): 956-958
    CrossrefPubMedGoogle Scholar
  • 40 Kouchoukos NT, Dávila-Román VG, Spray TL, Murphy SF, Perrillo JB. Replacement of the aortic root with a pulmonary autograft in children and young adults with aortic-valve disease. N Engl J Med 1994; 330 (01) 1-6
    CrossrefPubMedGoogle Scholar
  • 41 Elkins RC, Lane MM, McCue C. Pulmonary autograft reoperation: incidence and management. Ann Thorac Surg 1996; 62 (02) 450-455
    CrossrefPubMedGoogle Scholar
  • 42 Aboud A, Charitos EI, Fujita B. et al. Long-term outcomes of patients undergoing the Ross procedure. J Am Coll Cardiol 2021; 77 (11) 1412-1422
    CrossrefPubMedGoogle Scholar
  • 43 Romeo JLR, Papageorgiou G, da Costa FFD. et al. Long-term clinical and echocardiographic outcomes in young and middle-aged adults undergoing the Ross procedure. JAMA Cardiol 2021; 6 (05) 539-548
    CrossrefPubMedGoogle Scholar
  • 44 Pergola V, Di Salvo G, Fadel B. et al. The long term results of the Ross procedure: the importance of candidate selection. Int J Cardiol 2020; 320: 35-41
    CrossrefPubMedGoogle Scholar