Comparison between Valve Sparing Aortic Root Replacement and

Report
Comparison between Valve Sparing
Aortic Root Replacement and
Modified Bentall
Allan Stewart, MD., Jonathan A. Yang, MD; Mark J.
Russo, MD/MPH; Alexander Iribarne, MD; Brendan F.
Scully; Rachel Easterwood; Craig R. Smith, MD; Division
of Cardiothoracic Surgery, Columbia University Medical
Center, New York, NY
Aortic Insufficiency & Root Aneurysm
• Different treatment options exist
• Bentall Procedure1
– Several modifications
• Valve-sparing root replacement (VSRR)
– Sir Magdi Yacoub, Tirone David
• We have performed both at our Institution
since 2005
1. Bentall H, De Bono A. A technique for complete replacement of the ascending aorta. Thorax. 23(4):338-9.
Methods
• Retrospective study
• Peri-Operative and short-term data
• VSRR via the re-implantation method
described by David, et al1
• Modified Bentall Procedures – novel
composite biologic graft
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 April; 103(4):617-21.
Valve-Sparing Root Replacement
BioRoot
Edwards Perimount Valve
ATS 3f Valve
BioRoot
Results
Valve-Sparing
BioRoot
Root Replacement
Number of patients
111
175
Mean Age in years (Range)
55
63
Pre-Op AI 2+
75 (67.6%)
145 (82.6%)
Mean Cardiopulmonary
150.845.6
153.755.5
Bypass Time (min)
Mean Aortic Cross-Clamp
112.433.4
108.934.8
Time (min)
Post-Op AI 2+
0%
0%
Need for Re-op for AVR
2 (1.8%)
0 (0%)
30-day Mortality
1 (0.9%)
2 (1.1%)
p
<0.0001
0.0044
0.6
0.4
0.8
Pre-Treatment Decisions
Replace
Repair
“Real-time” Repair Algorithm (AI + Aneurysm)
Reimplantation
Can valve be
Repaired?
Ye
s
Should it be
Repaired?
Ye
s
Repair
Remodeling
N
o
Should it be
Replaced?
N
o
Ignore
Ye
s
BioRoot
Replace
Mechanical
Conduit
When Should We Repair?
• Aortic Leaflet Integrity
– Reliable valve-sparing results with:
• supple leaflets
• normal annular size
• Bicuspid and tri-leaflets have good 10-year data
– High Failure Rates with:
• Severe AI
• Multi-leaflet Prolapse
• Multiple Fenestrations
When Should We Replace?
• Marked leaflet Asymmetry
• Multiple leaflet Fenestrations
• “Broken leaflets”
• Bicuspid Patients
–
–
–
–
Significant Thickening
Prolapse
Calcification
Multiple Fenestrations
• Connective Tissue Patients
– Data is unclear
– Be cautious in repairing
attenuated & severely prolapsed
valves
Conclusions
•
•
•
•
•
Similar operative times
Low rates of post-op AI, repeat AVR and mortality
Similar short-term outcomes
Reproducible and safe
Need to delineate proper guidelines for
indications
• Follow-up needed to assess long-term outcomes

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