Early safety performance of a modified technique of aorta replacement with sinotubular stabilization
Marco MoscarelliNicola Di BariGiuseppe NassoKhalil FattouchThanos AthanasiouRaffaele BonifaziGiuseppe Speziale
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Abstract:
We sought to determine if a modified technique for ascending aorta replacement with sinotubular junction reduction and stabilization was safe.This technique was performed by suspension of the three commissures, invagination of the aortic Dacron graft and advancing the graft into the ventricles. We included patients with dilatation of the ascending aorta, normal sinuses of Valsalva dimension (<45 mm), with or without aortic annulus enlargement (>25 mm) and with various degree of aortic insufficiency (from grade 1 to 3).From April to October 2019, 20 patients were recruited from two centers; mean age was 66.9 ± 12.8 years, 13 were male; grade 1, 2 and 3 was present in 12, 2 and 6 patients, respectively. All patients underwent ascending aorta replacement with modified technique; an additional open subvalvular ring was used in 8 patients with aortic insufficiency ≥ 2; cusps repair was performed in 6 patients (5 plicating central stitches/1 shaving); concomitant coronary artery bypass grafting was performed in 10 patients. There was no 30-day mortality. One patient was re-explored for bleeding. All patients completed six-month follow-up; at the transthoracic echocardiography, there was no aortic insufficiency ≥ 1 except one patient with aortic insufficiency grade 1 who underwent ascending aorta replacement and subvalvular ring; no patients underwent reintervention.This modified technique for ascending aorta replacement and sinotubular junction stabilization was safe. It could be associated with other aortic valve sparing techniques. However, such remodeling approach has to be validated in a larger cohort of patients with longer follow-up.Keywords:
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Especially among elderly patients embolisms originating from atheromatous plaques in the ascending aorta are responsible for cardiac and cerebral events during coronary bypass surgery. Unfortunately smooth atheromatous degeneration of the aorta often can not be detected even by transoesophageal echocardiography.In four patients with unexpected atheromatous material of the punched ascending aorta the so called "wash out technique" was performed. A side-to-end anastomosis between a segment of vein and the partially clamped ascending aorta was performed. For several minutes the ascending aorta was left to bleed through the venous stump. Without further manipulation of the ascending aorta the coronary bypass graft was completed by an end-to-end anastomosis between the venous stump and the venous graft. Oral anticoagulation in combination with a low dose platelet antiaggregation drug was given for at least one year.All patients had an uncomplicated postoperative course, especially with regard to neurological damage or ECG changes.In patients with unexpected atheromatous pathology of the ascending aorta the "wash out technique" of coronary artery bypass grafting minimises direct embolisation into the cardiac area perfused by the new bypass grafts.
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[Introduction] The ideal mechanical prosthesis to replace the aortic valve in patients with a small aortic annulus remains controversial. The purpose of this study is to compare hemodynamic performance and clinical results of the SJM-HP with those of standard valves(Bjork-Shiley(B-S) and standard SJM) in patients with a small aortic annulus who received a patch enlargement. [Materials and Methods] Between 1975 and 1998, 33 patients received a 21mm SJM-HP (16 patients), a 21mm standard SJM(5 patients), or a 23mm B-S(12 patients) aortic prosthesis. For all patients who had one of the standard valves implanted the patch enlargement was performed using Nicks' method. Either doppler echocardiography or catheterization were performed both before and after the operation, and readings of flow velocity, and the pressure gradient across the valve were measured. [Results] There were no differences in flow velocity or pressure gradient between the groups. Moreover, we experienced no operative mortalities or significant perioperative complications. Peak and mean pressure gradients, along with flow velocity, in the 21mm SJM-HP group were significantly lower than the 21mm SJM group, in early postoperative and later follow-up periods. However, there were no statistical differences in these indices between the 21mm SJM-HP group and the 23mm B-S group seen at follow-up. [Conclusion] Based on our results, we believe that the 21mm SJM-HP should be selected for AVR when the preoperative aortic annulus diameter is approximately 22mm and for patch enlargement for a small aortic annulus when the preoperative aortic annulus diameter is below 20mm.
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External wrapping is a surgical method performed to prevent the dilatation of the aorta and to decrease the risk of its dissection and rupture. However, it is also believed to cause degeneration of the aortic wall. A biomechanical analysis was thus performed to assess the stress of the aortic wall subjected to external wrapping.A stress analysis using the finite elements method was carried out on three models: a non-dilated aorta, a moderately dilated aorta and a wrapped aorta. The models were subjected to a pulsatile flow (120/80 mmHg) and a systolic aortic annulus motion of 11 mm.The finite elements analysis showed that the stress exerted on the outer surface of the ascending aorta in the wrapping model (0.05-0.8 MPa) was similar to that observed in the normal aorta (0.03-0.7 MPa) and was lower than in the model of a moderately dilated aorta (0.06-1.4 MPa). The stress on the inner surface of the ascending aorta ranged from 0.2 MPa to 0.4 MPa in the model of the normal aorta, from 0.3 to 1.3 MPa in the model of the dilated aorta and from 0.05 MPa to 0.4 MPa in the wrapping model.The results of this study suggest that the aortic wall is subjected to similar stress following a wrapping procedure to the one present in the normal aorta.
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In 632 consecutive primary operations for coronary bypass grafting, the effect of instrumentation of the ascending aorta on the prevalence of stroke was evaluated. There were five surgical pathology groups: group A: soft aorta with no palpable disease, 463 patients; group B: distinctly palpable aorta with focal atheromas necessitating minor surgical modifications, 132 patients; group C, unclampable aorta (no plane for crossclamping the aorta without compression of atheromas was present), 16 patients; group D, untouchable aorta, in which the entire ascending aortic wall was involved by atheromatosis (these aortas were not touched), 14 patients; group E, aneurysmal aorta with soft walls, 7 patients. There were four strokes (0.63%), all related to instrumentations of the aorta. There were no cerebrovascular accidents in patients in whom precautions were taken. Of all risk factors studied, age was the only predictive one for major atheromatosis of the aorta (chi 2 test, p less than 0.001). Of the 30 patients in groups C and D, only one was younger than 60 years.
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Background— The objective was to evaluate the effects of aortic annulus size on valve hemodynamics and clinical outcomes in those patients included in the Placement of Aortic Transcatheter Valves (PARTNER) randomized controlled trial cohort A and the nonrandomized continued access cohort. Methods and Results— Patients included the randomized controlled trial (n=574) and nonrandomized continued access (n=1358) cohorts were divided in tertiles according to aortic annulus diameter (small aortic annulus tertile, medium aortic annulus tertile, and large aortic annulus tertile [LAA], respectively) as measured by transthoracic echocardiography. Severe prosthesis–patient mismatch was defined as an effective aortic orifice area of <0.65 cm 2 /m 2 . In the randomized controlled trial cohort, patients in the small aortic annulus tertile who underwent transcatheter aortic valve replacement had a lower incidence of severe prosthesis–patient mismatch (19.7% versus 37.5%; P =0.03) and only a trend toward a higher incidence of moderate-to-severe paravalvular leaks compared with surgical aortic valve replacement (5.7% versus 0%; P =0.06). In the LAA tertile, there were no differences in the rate of prosthesis–patient mismatch between groups, and a significant increase in moderate-to-severe paravalvular leaks was associated with transcatheter aortic valve replacement (9% versus 0%; P =0.01). There were no differences in mortality between transcatheter aortic valve replacement and surgical aortic valve replacement. In the nonrandomized continued access cohort, there were no differences in prosthesis–patient mismatch between the small aortic annulus and LAA tertiles, but a higher rate of moderate-to-severe paravalvular leaks was observed in the LAA tertile (5.9% versus 11.5%; P =0.009). Patients in the LAA tertile had a higher mortality rate at 1-year follow-up ( P =0.02), and differences persisted in multivariable analysis ( P =0.048 for LAA versus medium aortic annulus tertile, P =0.035 for LAA versus small aortic annulus tertile). Conclusions— Aortic annulus size had a major impact on valve hemodynamics and clinical outcomes after transcatheter aortic valve replacement and surgical aortic valve replacement. This study highlights the importance of considering aortic annulus size in the evaluation of high-risk patients who are candidates for aortic valve replacement. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00530894.
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We assessed the ability of transesophageal echocardiography (TEE) to examine the entire length of the ascending aorta. TEE-derived data were compared with anatomic measurements and epiaortic scanning. There were 27 patients (19 male, 8 female; aged 67 ± 12 yr) studied during cardiac surgery. The surgeon measured the distance between the aortic anulus near the right coronary artery to the origin of the innominate artery (AV→IN) and to the level of the aortic cannulation site (AV→C). Independently, the ascending aorta was imaged by biplane TEE and the maximum length of aorta visualized was measured (TEE-MAX). Additionally, TEE was used to detect atheromas in the aorta and to visualize the aortic cannula. Epiaortic scanning was also performed in 14 patients. Direct measurement of the ascending aorta revealed a length of 8.9 ± 1.3 cm (mean ± SD) and the TEE-MAX was 7.4 ± 1.1 cm. The range of the difference between the two measurements was 0.2-4.5 cm. The aortic cannula was visualized only in 1 of 27 patients, and severe atherosclerotic plaques (>3 mm thick), not seen on TEE, were detected in five patients with epiaortic scanning. As much as 42% (4.5 cm of 10.7 cm) of the length of the ascending aorta was not visualized and potentially embolic plaques were not imaged by TEE. These findings suggest that even biplane TEE may have limited use in the precannulation assessment of the aorta for plaque and the detection of distal ascending aortic pathology.
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