ObjectiveTo evaluate the short-term therapeutic effect of extended adventitial inversion with graft eversion anastomosis technique in the root treatment of acute type A aortic dissection (ATAAD).MethodsFrom November 2019 to July 2020, 28 patients with ATAAD were treated by extended adventitial inversion with graft eversion anastomosis technique in the Department of Cardiovascular Surgery, Dalian Municipal Central Hospital, including 19 males and 9 females, aged 60.11±11.11 years. The intima of the ascending aorta was trimed to 5 mm above the sinotubular junction. The adventitia of the ascending aorta was longitudinally cut to the reserved intima margin along the junction of the three aortic valves. The extended adventitial inversion was sutured continuously, no coronary sinus was sutured over the aortic annulus, and the left and right coronary sinus was sutured above the coronary ostium. The anastomotic graft was everted and inserted into the aortic lumen, and the everted graft was continuously sutured at the level of sinotubular junction which was 5 mm away from the edge of graft.ResultsThere was no intraoperative death, intractable root hemorrhage, residual root false lumen, root dilatation, anastomotic hematoma or other complications. There was no recurrence of the pain in the back of all patients, and the results of the CT angiography were not significantly changed. In 22 patients with no regurgitation, only 1 (4.55%) patient had a mild regurgitation. In 6 patients with mild aortic regurgitation, the disappearance rate of regurgitation was 50.0% (3/6).ConclusionThe treatment of extended adventitial inversion with graft eversion anastomosis technique in the root treatment of aortic dissection eliminates the residual dissection at the root. The anastomotic hemorrhage is prevented, the root structure of aortic dissection is reconstructed and strengthened, the root function is restored, and the possible expansion of the root is prevented. The short-term results are satisfactory.
This study aims to explore the effect of aortic sinus diameter on aortic valve opening and closing performance in the case of no obvious disease of aortic valve and annulus and continuous dilation of aortic root. A total of 25 three-dimensional aortic root models with different aortic sinus and root diameters were constructed according to the size of clinical surgical guidance. The valve sinus diameter DS is set to 32, 36, 40, 44 and 48 mm, respectively, and the aortic root diameter DA is set to 26, 27, 28, 29 and 30 mm, respectively. Through the structural mechanics calculation with the finite element software, the maximum stress, valve orifice area, contact force and other parameters of the model are analyzed to evaluate the valve opening and closing performance under the dilated state. The study found that aortic valve stenosis occurs when the DS = 32 mm, DA = 26, 27 mm and DS = 36 mm, DA = 26 mm. Aortic regurgitation occurs when the DS = 32, 36 and 40 mm, DA = 30 mm and DS = 44, 48 mm, DA = 29, 30 mm. The other 15 models had normal valve movement. The results showed that the size of the aortic sinus affected the opening and closing performance of the aortic valve. The smaller sinus diameter adapted with the larger root diameter and the larger sinus diameter adapted with the smaller root diameter. When the sinus diameter is 40 mm, the mechanical performance of the valve are good and it can well adapt with the relatively large range of aortic root dilation.
ObjectiveTo assess outcomes of transcatheter aortic valve replacement (TAVR) for pure native aortic valve regurgitation.MethodsA total of 129 patients underwent transfemoral TAVR in Fuwai Hospital from May 2019 to October 2020 were retrospectively analyzed. There were 83 males and 46 females with an average age of 72.26±8.97 years. The patients were divided into a pure native aortic valve regurgitation group (17 patients) and an aortic valve stenosis group (112 patients).ResultsThe incidence of valve in valve was higher in the pure native aortic valve regurgitation group (47.0% vs. 16.1%, P<0.01). There was no statistical difference between the two groups in conversion to surgery, intraoperative use of extracorporeal circulation, intraoperative left ventricular rupture, postoperative use of extracorporeal membrane oxygenation (ECMO), peripheral vascular complications, disabled stroke, death, or pacemaker implantation. There was no statistical difference in the diameter of annulus (25.75±2.21 mm vs. 24.70±2.90 mm, P=0.068) or diameter of outflow tract (25.82±3.75 mm vs. 25.37±3.92 mm, P=0.514) between the pure native aortic valve regurgitation group and the aortic valve stenosis group.ConclusionTransfemoral TAVR is a feasible method for patients with pure native aortic valve regurgitation. The diameter of annulus plane, the diameter of outflow tract and the shape of outflow tract should be evaluated.
ObjectiveTo investigate the application of computational fluid dynamics (CFD) in hemodynamic evaluation of aortic root reconstruction.MethodsThe clinical data of 1 patient with severe aortic valve stenosis was analyzed. Enhanced CT images were used as the original data, and professional software was used to reconstruct the three-dimensional (3D) model and fluid mechanics simulation of the aorta (including preoperative, postoperative and ideal conditions).ResultsThe 3D reconstruction model could directly present the distribution of valve calcification and the dilatation of the ascending aorta. The remodeled sinotubular junction and sinus structure were observed in the model under postoperative and ideal conditions. The improvement of ascending aorta dilatation was evaluated statistically by the diameter distribution before and after surgery. CFD simulation showed that the area of high flow velocity, pressure intensity and wall shear stress before surgery were consistent with the expansion area of the ascending aorta, and the restricted blood flow acceleration was observed at the angle between the arch and the descending aorta. In the ideal condition, the streamline of blood at the descending aorta was more stable and flat compared with preoperative or postoperative conditions, and there was no obvious abnormal high pressure and high wall shear stress area in the ascending aorta. The cardiopulmonary bypass time was 106 min, of which the aortic cross-clamp time was 60 min. The cardiac echocardiography indicated that the aortic valve worked well, and the peak systolic blood velocity was 1.7 m/s. The length of hospital stay after surgery was 12 d, including 2 d in ICU. The ventilator use time was 11.6 h. The patient did not have any remarkable discomfort during the 1-year follow-up.ConclusionCFD can be used to evaluate anatomic and hemodynamic abnormalities before aortic root reconstruction surgery. Postoperative reconstruction simulation can be performed again to evaluate the surgical effect, and meanwhile, virtual improvement can be tried for the unresolved problems to accumulate diagnosis and treatment experience, so as to provide patients with more accurate and personalized diagnosis and treatment procedure.
ObjectiveTo evaluate the feasibility and safety of Remodeling+Ring (modified Yacoub) for patients with aortic root aneurysm. MethodsThe clinical data of patients who underwent modified Yacoub surgery at West China Hospital of Sichuan University from July 2020 to May 2023 were retrospectively analyzed. ResultsFour male patients were enrolled, with an average age of 47.3±10.3 years and body surface area of 1.9±0.2 m2. One patient had a complication of bicuspid aortic valve. Aortic valve regurgitation was mild in three patients and moderate in one patient. Preoperative New York Heart Association (NYHA) heart function was gradeⅠin one patient and gradeⅡin three patients, and the body surface area was 1.9±0.2 m2. The maximum diameter of the aortic sinus was 59.3±8.1 mm. All four patients recovered and were discharged without a second thoracotomy. No postoperative complications such as brain injury, infection, respiratory failure or renal insufficiency occurred. During the follow-up of 17.0±13.1 months, two patients showed no regurgitation of the aortic valve, two patients exhibited mild regurgitation. Three patients had a heart function of gradeⅠ and one patient of gradeⅡ. ConclusionModified Yacoub technique is safe and effective for patients with aortic root aneurysm.
ObjectiveTo investigate and evaluate the safety and efficacy of Bentall operation in the reoperation of patients with small aortic root or annulus.MethodsBentall procedure was performed in 24 patients with small aortic root or annulus in our hospital from September 2014 to December 2019. There were 18 males and 6 females with a mean age of 31-68 (45.70±15.27) years. All patients had undergone a previous replacement of the aortic valve including 20 patients receiving valve replacement, 2 patients aortic root replacement with a valved conduit and 2 patients bioprothesis replacement.ResultsThere was no early death in hospital and one death during the 30-day postoperative period. Re-thoracotomy due to bleeding was necessary in only 2 patients and no bleeding was related to the proximal anastomosis of the conduit. One patient performed pacemaker implantation for heart block after the procedure. The mean sizes of implanted aortic valve prosthesis were 22.75±1.78 mm. A mean gradient across the aortic valve prostheses in the postoperative echocardiographic examination was 11.17±2.24 mm Hg.ConclusionBentall procedure is safe and allows a larger size of prosthesis implantation in patients with small aortic annulus or root after previous aortic valve or complete root replacement, resulting in good postoperative hemodynamic characteristics and short-term clinical results.
ObjectiveTo explore growth pattern of neo-aortic root as well as development of neo-aortic regurgitation after arterial switch operation (ASO) for Taussig-Bing anomaly. MethodsFrom 2002 to 2017, the patients who received ASO, and were discharged alive from Shanghai Children’s Medical Center and followed up for more than 3 years were retrospectively involved in this study. ResultsA total of 127 patients were enrolled. There were 98 (77.2%) males, the median age at ASO was 73.0 d and the average weight was 4.7 kg. Forty-five (35.4%) children were complicated with mild or mild-to-moderate pulmonary insufficiency (PI) before ASO. The average follow-up time was 7.0 years. During the follow-up, 14 (11.0%) children presented moderate or greater neo-aortic regurgitation (neo-AR). The diameter of neo-aortic annulus and sinus of Valsalva was beyond normal range during the entire follow-up. The average diameter of neo-aortic annulus was 18.0 mm at 5 years and 20.5 mm at 10 years. The average diameter of sinus of Valsalva was 25.9 mm at 5 years and 31.1 mm at 10 years. Neo-AR continued to develop over time. The diameter of children who developed moderate or greater neo-AR was constantly larger than that of children who did not (χ2=18.3, P<0.001). Preoperative mild or mild-to-moderate PI was an independent risk factor for the development of moderate or greater neo-AR during mid-to-long term follow-up (c-HR=3.46, P=0.03). ConclusionThe diameters of neo-aortic annulus and sinus of Valsalva of Taussig-Bing children who receive ASO repair continue to expand without normalization. The dilation of annulus correlates with the development of neo-AR. PI before ASO repair increases the risk of neo-AR development.
Objective To evaluate the early clinical effect of reimplantation in the treatment of bicuspid aortic valve (BAV) with aortic root aneurysm. Methods The clinical data of 25 patients with BAV and aortic root aneurysm[mean diameter: 45-63 (52.68±5.55) mm] undergoing reimplantation in West China Hospital from November 2019 to May 2021 were retrospectively reviewed. There were 22 males and 3 females. The mean age was 15-65 (50.00±13.10) years and body surface area was 1.79±0.23 m2. ResultsThe pathological classification of BAV malformation was confirmed during the operation: Type 0 in 3 patients and Type 1 in 22 patients. There were 12 patients undergoing cusp central plication, and 2 patients were sutured with a closed fusion crest. Postoperative valve leaflet coaptation height was 0.78±0.15 cm, and effective height was 1.27±0.19 cm. In operation, maximum aortic valve flow velocity was 1.65±0.42 m/s, pressure difference was 5.46±3.05 mm Hg, and aortic valve annulus diameter was 21.32±0.95 mm. Cardiopulmonary bypass time was 225.84±35.34 min, and aortic block time was 189.60±26.51 min. In-hospital time was 11.64±3.07 d, ICU stay time was 2.64±0.99 d, and mechanical ventilation time was 1.48±0.87 d. The follow-up time was 17.20±4.70 months, and no death or major complications occurred during the follow-up in all patients. The cardiac function of the patients significantly improved postoperatively (P≤0.05). Echocardiography suggested that 12 patients had no aortic regurgitation, 10 minor aortic regurgitation, 3 mild aortic regurgitation, and no patients with moderate or more severe regurgitation. The diameter of the aortic sinus, left ventricular end-diastolic diameter and volume decreased during the follow-up, compared to preoperative ones (P≤0.05). The maximum flow velocity of the aortic valve was 1.54±0.36 m/s, and the pressure difference was 5.17±2.38 mm Hg during the follow-up. ConclusionReimplantation technology has a good clinical effect for highly selective BAV patients. It can effectively avoid long-term postoperative anticoagulation, but the maximum flow rate after surgery is slightly increased, which may be related to the configuration of BAV itself. While compared with valve replacement, the effect is still worthy of recognition.
Objective To investigate and evaluate the safety and efficacy of the aortic-mitral annular enlargement technique (double annular enlargement) in patients with small-size valve prostheses after prior valve surgery. MethodsThe clinical data of patients who underwent double valve annular enlargement in Wuhan Asia Heart Hospital from April 2020 to April 2022 were retrospectively analyzed. Results A total of 30 patients were collected, including 2 males and 28 females aged 9-78 (52.71±3.53) years. All patients had previous heart valve surgery, including 1 patient receiving the third heart surgery. All patients were operated on successfully and there were no postoperative in-hospital deaths. There was no postoperative bleeding which needed a secondary open-chest hemostasis, and one patient underwent permanent pacemaker implantation due to postoperative sick sinus syndrome. The mean diameter of the implanted prosthetic aortic valve was 24.23±1.60 mm, which was significantly larger than that of the preoperative aortic valve (21.03±1.90 mm, P＜0.001). The mean diameter of the implanted prosthetic mitral valve was 28.33±1.21 mm, which was significantly larger than that of the preoperative mitral valve (25.43±0.84 mm, P＜0.001). The mean peak gradient difference across the prosthetic aortic valve on postoperative echocardiography was 18.17±6.44 mm Hg, which was significantly lower than that of the preoperative aortic valve (82.57±24.48 mm Hg, P＜0.001). The mean peak gradient difference of the postoperative prosthetic mitral valve was 12.73±5.45 mm Hg, which was significantly lower than that of the preoperative mitral valve (19.43±8.97 mm Hg, P=0.003). Conclusion The double annular enlargement technique is safe and effective for reoperation in patients with a history of valve surgery with a small aortic root to obtain both a larger size prosthetic valve for a larger orifice area and stability of the mitral-aortic valve union, resulting in good postoperative hemodynamic characteristics and clinical outcomes.
Total root replacement (TRR) with a valved conduit has long been the treatment standard for most aortic root diseases. However, with advances in technology and a deeper understanding of aortic root anatomy and hemodynamics, valve-sparing aortic root replacement (VSRR) and personalised external aortic root support (PEARS) have emerged. It is especially important to choose the appropriate procedure for different aortic root diseases. When evaluating these three surgical procedures, it is necessary to focus on the treatment and prevention of the dissection and balance the short-term and long-term risks of the patients. This article outlines aortic-related diseases and the selection of surgery.