Aortic Regurgitation After Valve-Sparing Aortic Root Replacement: Modes of Failure (original) (raw)

2011, The Annals of Thoracic Surgery

Background. Despite the positive clinical results of valve-sparing aortic root replacement, little is known about the causes of reoperations and the modes of failure. Methods. From October 1999 to June 2010, 101 patients underwent valve-sparing aortic root replacement using the David reimplantation technique. The definition of aortic root repair failure included the following: (1) intraoperative conversion to the Bentall procedure; (2) reoperation performed because of aortic regurgitation; and (3) aortic regurgitation equal to or greater than a moderate degree at the follow-up. Sixteen patients were considered to have repair failure. Three patients required intraoperative conversion to valve replacement, 3 required reoperation within 3 months, and another 8 required reoperation during postoperative follow-up. At initial surgery 5 patients had moderate to severe aortic regurgitation, 6 patients had acute aortic dissections, 3 had Marfan syndrome, 2 had status post Ross operations, 3 had bicuspid aortic valves, and 1 had aortitis. Five patients had undergone cusp repair, including Arantius plication in 3 and plication at the commissure in 2. Results. The causes of early failure in 6 patients included cusp perforation (3), cusp prolapse (3), and severe hemolysis (1). The causes of late failure in 10 patients included cusp prolapse (4), commissure dehiscence (3), torn cusp (2), and cusp retraction (1). Patients had valve replacements at a mean of 23 ؎ 20.9 months after reimplantation and survived. Conclusions. Causes of early failure after valve-sparing root replacement included technical failure, cusp lesions, and steep learning curve. Late failure was caused by aortic root wall degeneration due to gelatin-resorcinformalin glue, cusp degeneration, or progression of cusp prolapse. (Ann Thorac Surg 2011;92:1639 -45) A lthough the indications for aortic valve-sparing operation for annulo-aortic ectasia have been expanded, some patients require reoperation because of recurrent or residual aortic regurgitation (AR) [1, 2]. This study aims to clarify the causes of AR after valve-sparing aortic root replacement. patients underwent aortic root replacement consisting of 98 valve-sparing operations, 41 Bentall operations and 17 stentless valve root replacements. In the 101 patients who had valve-sparing operations, the preoperative degree of AR was none to a trace in 4, mild in 26, moderate in 35, and severe in 36. The causes of AR included degenerative aortic cusp and wall disease in 59, Marfan syndrome in 24, acute aortic dissection in 18, bicuspid aortic valve in 12, aortitis in 4, and redo surgery in 10. Aortic root reimplantation (David) was performed in 100 patients; from July 2002 onward, Valsalva grafts were exclusively used. One patient had aortic root remodeling (Yacoub). The age at operation ranged from 13 to 75 years, with an average age of 49.7 Ϯ 15.9 years (65 men and 33 women).