**5. Outcomes of valve-sparing aortic root replacement and valve repair**

Dr Tirone David and colleagues from the Toronto Group recently published their results on 289 patients undergoing valve-sparing aortic root replacement using both the re-implantation (n=228) and remodelling (n=61) techniques [12]. Nine percent of patients underwent surgery for acute type A dissection. Overall, freedom from recurrent regurgitation was high at 86.8% ± 3.8% at 12 years follow-up. Patients undergoing the re-implantation technique experienced greater freedom from recurrent regurgitation compared to those undergoing remodeling (91.0% ± 3.8% versus 82.6% ± 6.2%, p = 0.035), however technique was not an independent predictor of late recurrent regurgitation. In this publication, the Toronto Group also showed that patient survival after undergoing valve-reimplantation was comparable to that of the general population when matched for age and gender.

The largest published series on the re-implantation technique is from Kallenbach and colleagues from Hannover, Germany, who in 2005, published their results of 284 consecutive patients undergoing the re-implantation procedure [20]. The series showed that the reimplantation procedure leads to excellent mid-term and late outcomes with freedom from re-operation due to recurrent aortic regurgitation was 91.1±2.5% at 5 years and 87.1±4.5% at 10 years. Late survival at 10 years was also high at 80.4±5.7% at 10 years.

In recent years, most surgeons have favoured the re-implantation technique, given the reinforcement of the aortic annulus which prevents subsequent dilatation, which is particularly important in patients with connective tissue diseases such as Marfan syndrome. Indeed, the evidence suggests that the re-implantation technique is less likely to result in recurrent regurgitation in the long-term [12, 21].

#### **5.1 Valve-sparing root replacement with concomitant valve repair**

Valve-sparing aortic root replacement was principally conceived for patients with morphologically normal valve leaflets where aortic regurgitation was caused solely by a dilated root. They were initially applied to patients with early grades of aortic regurgitation and less severe aortic root dilatation where the leaflets have only been minimally stretched.

However, combining leaflet prolapse correction with aortic valve sparing techniques permits extension of the benefits of valve sparing procedures to patients with advanced aortic regurgitation or aneurysms. In the past decade, there has been growing interest in such an approach.

In David and colleagues' earlier experience, published in 2001 [22], only 11% of patients underwent repair of cusp prolapse. However, almost a decade later, the group's latest report shows that 40% of patients had at least one leaflet free margin plicated while 22% underwent reinforcement of the free margin with a running polytetreafluoroethylene suture [12].

In a seminal publication, the Brussels Group, recently presented their results on 264 patients undergoing elective aortic valve repair for regurgitation occuring in isolation (43%) and in combination with aortic dilatation (57%) [8]. Leaflet repair techniques included free margin plication, resuspension as well as trangular resection with pericardial patch repair, while

Valve-Sparing Aortic Root Replacement and Aortic Valve Repair 101

A recent report from Luebeck presenting data on 191 remodeling and re-implantation procedures suggested that cusp repair was associated with an increased rate of late recurrent regurgitation. The authors attributed this to a number of factors including the presence of valves unsuitable for repair, fibrotic retraction of the repaired cusps, improper surgical techniques and other tissue properties [24]. Indeed, in our recent published experience, we observed a trend towards greater recurrent regurgitation in patients who had prolapsed

We have addressed this by use of more aggressive valve reinforcement with free margin running polytetrafluoroethylene sutures in selected patients with particularly stretched leaflets. Furthermore, in extreme cases, valve-preservation is judiciously avoided with replacement performed instead. In doing so, we hope to minimize the rate of recurrent aortic regurgitation such that it approaches the level seen in patients without leaflet

> 19 12 8 7 5 4 42 22 15 7 5 3

0 12 24 36 48 60 **Months** *Reprinted from the European Journal of Cardio-Thoracic Surgery, 2010;37:6, Matalanis G, Shi WY, Hayward PAR, Correction of leaflet prolapse extends the spectrum of patients suitable for valve-sparing aortic root* 

Fig. 13. Our local experience with valve-sparing aortic root replacement with concomitant

Even if we acknowledge an early marginal reduction in valve durability after very aggressive prolapse correction, it is still an excellent option for many patients, particularly those for whom long term anticoagulation is unacceptable, as seems increasingly common in

The largest reported series concerning repair of bicuspid aortic valves again comes from the Brussels Group, who recently published their outcomes on 122 consecutive patients undergoing bicuspid repair [25]. Of these, 57% had aortic regurgitation due to aortic dilatation while the remaining exhibited isolated valve insufficiency. Free margin plication and resuspension was performed in the 20% of patients with anatomically bicuspid (Type 0)

100% at 5 years 82 ± 7.5% at 5 years Log rank p = 0.12

leaflets, which did not reach statistical significance [16] (Fig. 13).

Normal leaflets Prolapsing leaflet(s)

Patients at risk

*replacement.1311-1316., Copyright (2010), with permission from Elsevier* 

prolapse.

valve repair

clinical practice.

**5.2 Bicuspid aortic valves** 

100

80

60

**Freedom from >2+ AR (%)**

40

20

0

combinations of valve-sparing procedures, sinotubular plication, and subcommissural annuloplasty was used to stabilise the annulus. The series is notable in that pre-operatively, 75% of patients had >2+ aortic regurgitation with a mean aortic diameter of 53 ± 9mm, suggesting the presence of long-standing disease whereby leaflets were reasonably stretched, which a decade ago would have been viewed to be a relative contraindication to valve preservation. Despite this, Freedoms from aortic regurgitation greater than 2+ were high at 88± 3% at 5 years and 79± 11% at 8 years, reflecting good durability of repair [8].

In a separate paper, the group reported their results on 111 patients with tri-leaflet valves undergoing repair of cusp prolapse with (n=61) or without (n=50) an associated aortic aneurysm. The re-implantation and sub-commissural annuloplasty techniques were predominantely used to correct aortic root dimensions, while free margin plication and resuspension were performed for cusp repair. At 8 years, freedom from recurrent regurgitation was high at 93±5% and 87±7% for patients with and without aortic aneurysms respectively. The number of cusps repaired and the technique used were not associated with recurrent regurgitation [23].

Performing valve repair alongside valve-sparing root replacement has gained popularity in recent years with several groups finding it to lead to strong mid-term results, with most studies reporting 5 year freedom from recurrent regurgitation rates of 85-95%.

We recently reported our local experience of 61 cases [16] with a relatively aggressive approach towards valve-preservation. Seventy-seven percent of patients had >2+ aortic regurgitation pre-operatively and a total of 69% of patients in the series required aortic valve repair for prolapse (Fig. 12). At mid-term follow-up, 5-year freedom from recurrent regurgitation was encouraging at 88±5.3%.

*Reprinted from the European Journal of Cardio-Thoracic Surgery, 2010;37:6, Matalanis G, Shi WY, Hayward PAR, Correction of leaflet prolapse extends the spectrum of patients suitable for valve-sparing aortic root replacement.1311-1316., Copyright (2010), with permission from Elsevier* 

Fig. 12. In our local experience, greater than 2+ regurgitation and leaflet prolapse was present in a significant proportion of patients

combinations of valve-sparing procedures, sinotubular plication, and subcommissural annuloplasty was used to stabilise the annulus. The series is notable in that pre-operatively, 75% of patients had >2+ aortic regurgitation with a mean aortic diameter of 53 ± 9mm, suggesting the presence of long-standing disease whereby leaflets were reasonably stretched, which a decade ago would have been viewed to be a relative contraindication to valve preservation. Despite this, Freedoms from aortic regurgitation greater than 2+ were high at

In a separate paper, the group reported their results on 111 patients with tri-leaflet valves undergoing repair of cusp prolapse with (n=61) or without (n=50) an associated aortic aneurysm. The re-implantation and sub-commissural annuloplasty techniques were predominantely used to correct aortic root dimensions, while free margin plication and resuspension were performed for cusp repair. At 8 years, freedom from recurrent regurgitation was high at 93±5% and 87±7% for patients with and without aortic aneurysms respectively. The number of cusps repaired and the technique used were not associated with

Performing valve repair alongside valve-sparing root replacement has gained popularity in recent years with several groups finding it to lead to strong mid-term results, with most

We recently reported our local experience of 61 cases [16] with a relatively aggressive approach towards valve-preservation. Seventy-seven percent of patients had >2+ aortic regurgitation pre-operatively and a total of 69% of patients in the series required aortic valve repair for prolapse (Fig. 12). At mid-term follow-up, 5-year freedom from recurrent

> Aortic Regurgitation Leaflet prolapse

> > 21

13

26

23

88± 3% at 5 years and 79± 11% at 8 years, reflecting good durability of repair [8].

studies reporting 5 year freedom from recurrent regurgitation rates of 85-95%.

10

4 4

2

*Reprinted from the European Journal of Cardio-Thoracic Surgery, 2010;37:6, Matalanis G, Shi WY, Hayward PAR, Correction of leaflet prolapse extends the spectrum of patients suitable for valve-sparing aortic root* 

Fig. 12. In our local experience, greater than 2+ regurgitation and leaflet prolapse was

1+ 2+ 3+ 4+ **Aortic Regurgitation**

recurrent regurgitation [23].

regurgitation was encouraging at 88±5.3%.

30

20

**Patients**

10

0

present in a significant proportion of patients

*replacement.1311-1316., Copyright (2010), with permission from Elsevier* 

A recent report from Luebeck presenting data on 191 remodeling and re-implantation procedures suggested that cusp repair was associated with an increased rate of late recurrent regurgitation. The authors attributed this to a number of factors including the presence of valves unsuitable for repair, fibrotic retraction of the repaired cusps, improper surgical techniques and other tissue properties [24]. Indeed, in our recent published experience, we observed a trend towards greater recurrent regurgitation in patients who had prolapsed leaflets, which did not reach statistical significance [16] (Fig. 13).

We have addressed this by use of more aggressive valve reinforcement with free margin running polytetrafluoroethylene sutures in selected patients with particularly stretched leaflets. Furthermore, in extreme cases, valve-preservation is judiciously avoided with replacement performed instead. In doing so, we hope to minimize the rate of recurrent aortic regurgitation such that it approaches the level seen in patients without leaflet prolapse.

*Reprinted from the European Journal of Cardio-Thoracic Surgery, 2010;37:6, Matalanis G, Shi WY, Hayward PAR, Correction of leaflet prolapse extends the spectrum of patients suitable for valve-sparing aortic root replacement.1311-1316., Copyright (2010), with permission from Elsevier* 

Fig. 13. Our local experience with valve-sparing aortic root replacement with concomitant valve repair

Even if we acknowledge an early marginal reduction in valve durability after very aggressive prolapse correction, it is still an excellent option for many patients, particularly those for whom long term anticoagulation is unacceptable, as seems increasingly common in clinical practice.

#### **5.2 Bicuspid aortic valves**

The largest reported series concerning repair of bicuspid aortic valves again comes from the Brussels Group, who recently published their outcomes on 122 consecutive patients undergoing bicuspid repair [25]. Of these, 57% had aortic regurgitation due to aortic dilatation while the remaining exhibited isolated valve insufficiency. Free margin plication and resuspension was performed in the 20% of patients with anatomically bicuspid (Type 0)

Valve-Sparing Aortic Root Replacement and Aortic Valve Repair 103

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[9] Dujardin KS, Enriquez-Sarano M, Schaff HV, Bailey KR, Seward JB, Tajik AJ. Mortality

[10] David TE., Feindel CM. An aortic valve-sparing operation for patients with aortic

[11] Sarsam MA, Yacoub M. Remodeling of the aortic valve anulus. J Thorac Cardiovasc

[12] David TE, Maganti M, Armstrong S. Aortic root aneurysm: Principles of repair and

[13] David TE. The aortic valve-sparing operation. J Thorac Cardiovasc Surg 2011 141:613-

[14] Demers P, Miller DC. Simple modification of "T. David-v" Valve-sparing aortic root replacement to create graft pseudosinuses. Ann Thorac Surg 2004 78:1479-1481. [15] De Paulis R, De Matteis GM, Nardi P, Scaffa R, Buratta MM, Chiariello L. Opening and

[16] Matalanis G, Shi WY, Hayward PA. Correction of leaflet prolapse extends the spectrum

[17] Fleischer KJ, Nousari HC, Anhalt GJ, Stone CD, Laschinger JC. Immunohistochemical

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[21] Liu L, Wang W, Wang X, Tian C, Meng YH, Chang Q. Reimplantation versus

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valves. Those with functionally bicuspid (Type 1) valves, raphe repair was accomplished by either shaving, resection or use of a pericardial patch. At 5 years, freedom from recurrent regurgitation was high at 94±3%. Furthermore, in unadjusted analyses, patients undergoing a root procedure (remodelling or reimplantation) had a greater freedom from recurrent regurgitation compared to those undergoing subcommissural annuloplasty or sinotubular junction plication (95± 5%vs 80±6% at 5 years, p=0.03) [25].
