Progress in surgical selection of aortic root diseases_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

CUI Jinshuai ¹ , CHAO Wenhan ¹ , GAO Bingren ² ,  LIU Debin ²

1. Lanzhou University Second Hospital, Lanzhou, 730030, P.R.China;
2. Department 1 of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, 730030, P.R.China;

Corresponding author：

LIU Debin, Email: liudebin01@sina.com

Keywords：

Total root replacement (TRR); valve-sparing aortic root replacement (VSRR); personalised external aortic root support (PEARS)

DOI：

10.7507/1007-4848.201808013

Video：

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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.

Citation： CUI Jinshuai, CHAO Wenhan, GAO Bingren, LIU Debin. Progress in surgical selection of aortic root diseases. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2019, 26(5): 504-508. doi: 10.7507/1007-4848.201808013 Copy

1.	Zacek P, Holubec T, Vobornik M, et al. Quality of life after aortic valve repair is similar to Ross patients and superior to mechanical valve replacement: a cross-sectional study. BMC Cardiovasc Disord, 2016, 16: 63.
2.	Treasure T, Takkenberg JJ, Pepper J. Surgical management of aortic root disease in Marfan syndrome and other congenital disorders associated with aortic root aneurysms. Heart, 2014, 100(20): 1571-1576.
3.	卢子润, 王东进. 主动脉瓣关闭不全行主动脉瓣成形术的治疗进展. 中国胸心血管外科临床杂志, 2018, 25(2): 177-180.
4.	Lansac E, Lim HS, Shomura Y, et al. A four-dimensional study of the aortic root dynamics. Eur J Cardiothorac Surg, 2002, 22(4): 497-503.
5.	Spadaccio C, Nappi F, Al-Attar N, et al. Old myths, new concerns: the long-term effects of ascending aorta replacement with dacron grafts. Not all that glitters is gold. J Cardiovasc Transl Res, 2016, 9(4): 334-342.
6.	Bentall H, De Bono A. A technique for complete replacement of the ascending aorta. Thorax, 1968, 23(4): 338-339.
7.	王春生, 李军, 赖颢. Stanford A 型主动脉夹层根部重建技术的应用现状与思考. 中华外科杂志, 2017, 55(4): 245-250.
8.	Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol, 2017, 70(2): 252-289.
9.	Etz CD, Bischoff MS, Bodian C, et al. The Bentall procedure: is it the gold standard? A series of 597 consecutive cases. J Thorac Cardiovasc Surg, 2010, 140(6 Suppl): S64-S70.
10.	Kim TS, Na CY, Oh SS, et al. Long-term mortality and morbidity after button Bentall operation. J Card Surg, 2013, 28(3): 280-284.
11.	Li K, Wang Q, Pham T, et al. Quantification of structural compliance of aged human and porcine aortic root tissues. J Biomed Mater Res A, 2014, 102(7): 2365-2374.
12.	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, 103(4): 617-621.
13.	Pepper J, Yacoub M. Valve conserving operation for aortic regurgitation. J Card Surg, 1997, 12(2 Suppl): 151-156.
14.	孙立忠, 刘宁宁. 保留主动脉瓣的根部替换术 (David 手术). 中华胸心血管外科杂志, 2012, 28(9): 572-576.
15.	Monsefi N, Zierer A, Risteski P, et al. Long-term results of aortic valve resuspension in patients with aortic valve insufficiency and aortic root aneurysm. Interact Cardiovasc Thorac Surg, 2014, 18(4): 432-437.
16.	Bori Bata AK, D’Ostrevy N, Pereira B, et al. Valve-sparing aortic root replacement-midterm outcomes and quality of life. Cardiovasc Diagn Ther, 2017, 7(6): 572-580.
17.	Svensson LG, Pillai ST, Rajeswaran J, et al. Long-term survival, valve durability, and reoperation for 4 aortic root procedures combined with ascending aorta replacement. J Thorac Cardiovasc Surg, 2016, 151(3): 764-774.
18.	Urbanski PP, Lenos A, Irimie V, et al. Acute aortic dissection involving the root: operative and long-term outcome after curative proximal repair. Interact Cardiovasc Thorac Surg, 2016, 22(5): 620-626.
19.	Yunoki J, Nakayama Y, Oonishi H, et al. Partial aortic root remodeling with an adventitial inversion technique for an acute type a aortic dissection. J Card Surg, 2010, 25(3): 327-329.
20.	Fujimatsu T, Osawa H, Osaka S, et al. Strategies for treatment of acute aortic dissection with involvement of sinus of valsalva. Ann Thorac Cardiovasc Surg, 2009, 15(6): 382-388.
21.	Huang F, Li L, Qin W, et al. Partial aortic root remodeling for root reconstruction in patients with acute type A dissection. J Biomed Res, 2016, 30(5): 411-418.
22.	Fleischer KJ, Nousari HC, Anhalt GJ, et al. Immunohistochemical abnormalities of fibrillin in cardiovascular tissues in Marfan’s syndrome. Ann Thorac Surg, 1997, 63(4): 1012-1017.
23.	Song HK, Preiss LR, Maslen CL, et al. Valve-sparing aortic root replacement in patients with Marfan syndrome enrolled in the National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions. J Heart Valve Dis, 2014, 23(3): 292-298.
24.	Price J, Magruder JT, Young A, et al. Long-term outcomes of aortic root operations for Marfan syndrome: A comparison of Bentall versus aortic valve-sparing procedures. J Thorac Cardiovasc Surg, 2016, 151(2): 330-336.
25.	Coselli JS, Weldon SA, Preventza O, et al. Valve-sparing versus composite root replacement procedures in patients with Marfan syndrome. Ann Cardiothorac Surg, 2017, 6(6): 692-696.
26.	Semaan E, Markl M, Malaisrie SC, et al. Haemodynamic outcome at four-dimensional flow magnetic resonance imaging following valve-sparing aortic root replacement with tricuspid and bicuspid valve morphology. Eur J Cardiothorac Surg, 2014, 45(5): 818-825.
27.	den Hartog AW, Franken R, Zwinderman AH, et al. The risk for type B aortic dissection in Marfan syndrome. J Am Coll Cardiol, 2015, 65(3): 246-254.
28.	Lacro RV, Dietz HC, Sleeper LA, et al. Atenolol versus losartan in children and young adults with Marfan’s syndrome. N Engl J Med, 2014, 371(22): 2061-2071.
29.	Biner S, Rafique AM, Ray I, et al. Aortopathy is prevalent in relatives of bicuspid aortic valve patients. J Am Coll Cardiol, 2009, 53(24): 2288-2295.
30.	Tadros TM, Klein MD, Shapira OM. Ascending aortic dilatation associated with bicuspid aortic valve: pathophysiology, molecular biology, and clinical implications. Circulation, 2009, 119(6): 880-890.
31.	Malvindi PG, Cappai A, Basciu A, et al. David operation: single center 10-year experience. J Cardiovasc Surg (Torino), 2015, 56(4): 639-645.
32.	Losenno KL, Goodman RL, Chu MW. Bicuspid aortic valve disease and ascending aortic aneurysms: gaps in knowledge. Cardiol Res Pract, 2012, 2012: 145202.
33.	Bavaria JE, Desai N, Szeto WY, et al. Valve-sparing root reimplantation and leaflet repair in a bicuspid aortic valve: comparison with the 3-cusp David procedure. J Thorac Cardiovasc Surg, 2015, 149(2 Suppl): S22-S28.
34.	Loeys BL, Chen J, Neptune ER, et al. A syndrome of altered cardiovascular, craniofacial, neurocognitive and skeletal development caused by mutations in TGFBR1 or TGFBR2. Nat Genet, 2005, 37(3): 275-281.
35.	Schepers D, Tortora G, Morisaki H, et al. A mutation update on the LDS-associated genes TGFB2/3 and SMAD2/3. Hum Mutat, 2018, 39(5): 621-634.
36.	Sim HT, Seo DJ, Yu JJ, et al. Valve sparing aortic root replacement in children with Loeys-Dietz syndrome. Korean J Thorac Cardiovasc Surg, 2015, 48(4): 272-276.
37.	Patel ND, Crawford T, Magruder JT, et al. Cardiovascular operations for Loeys-Dietz syndrome: Intermediate-term results. J Thorac Cardiovasc Surg, 2017, 153(2): 406-412.
38.	Yamauchi H, Nawata K, Takeda N, et al. Abstract 20109: Midterm outcome of valve-sparing aortic root replacement in Loeys-Dietz syndrome. Circulation, 2018, 136: A20109.
39.	Liu RH, Fraser CD 3rd, Zhou X, et al. Pseudoaneurysm formation after valve sparing root replacement in children with Loeys-Dietz syndrome. J Card Surg, 2018, 33(6): 339-343.
40.	DeNino WF, Toole JM, Rowley C, et al. Comparison of David Ⅴ valve-sparing root replacement and bioprosthetic valve conduit for aortic root aneurysm. J Thorac Cardiovasc Surg, 2014, 148(6): 2883-2887.
41.	Esaki J, Leshnower BG, Binongo JN, et al. Clinical outcomes of the David Ⅴ valve-sparing root replacement compared with bioprosthetic valve-conduits for aortic root aneurysms. Ann Thorac Surg, 2017, 103(6): 1824-1832.
42.	Cho SH, Kim DH, Kwak YT. Valve-sparing root replacement: aortic root remodeling with external subvalvular ring annuloplasty. Korean J Thorac Cardiovasc Surg, 2016, 49(6): 489-492.
43.	Lenoir M, Maesen B, Stevens LM, et al. Reimplantation versus remodelling with ring annuloplasty: comparison of mid-term outcomes after valve-sparing aortic root replacement. Eur J Cardiothorac Surg, 2018, 54(1): 48-54.
44.	Andersen ND, Williams JB, Harrison JK, et al. Ascending-descending aortic bypass with valve-sparing root replacement for coarctation with aortic root aneurysm. J Thorac Cardiovasc Surg, 2012, 143(2): 514-515.
45.	Yoneyama F, Okamura T, Harada Y, et al. Valve-sparing reimplantation for neoaortic root dilatation and regurgitation with an unbalanced cusp after the arterial switch operation. J Card Surg, 2018, 33(2): 122-125.
46.	Izgi C, Nyktari E, Alpendurada F, et al. Effect of personalized external aortic root support on aortic root motion and distension in Marfan syndrome patients. Int J Cardiol, 2015, 197: 154-160.
47.	Singh SD, Xu XY, Pepper JR, et al. Effects of aortic root motion on wall stress in the Marfan aorta before and after personalised aortic root support (PEARS) surgery. J Biomech, 2016, 49(10): 2076-2084.
48.	Bauer M, Grauhan O, Hetzer R. Dislocated wrap after previous reduction aortoplasty causes erosion of the ascending aorta. Ann Thorac Surg, 2003, 75(2): 583-584.
49.	Verbrugghe P, Verbeken E, Pepper J, et al. External aortic root support: a histological and mechanical study in sheep. Interact Cardiovasc Thorac Surg, 2013, 17(2): 334-339.
50.	Treasure T, Takkenberg JJ, Golesworthy T, et al. Personalised external aortic root support (PEARS) in Marfan syndrome: analysis of 1-9 year outcomes by intention-to-treat in a cohort of the first 30 consecutive patients to receive a novel tissue and valve-conserving procedure, compared with the published results of aortic root replacement. Heart, 2014, 100(12): 969-975.
51.	Austin C, Mathur SK, Pepper J. Personalised external aortic root support (PEARS): Utilisation in dilatational aortopathies after the arterial switch operation V4. Int J Cardiol, 2016, 220: 772-774.

1. Zacek P, Holubec T, Vobornik M, et al. Quality of life after aortic valve repair is similar to Ross patients and superior to mechanical valve replacement: a cross-sectional study. BMC Cardiovasc Disord, 2016, 16: 63.
2. Treasure T, Takkenberg JJ, Pepper J. Surgical management of aortic root disease in Marfan syndrome and other congenital disorders associated with aortic root aneurysms. Heart, 2014, 100(20): 1571-1576.
3. 卢子润, 王东进. 主动脉瓣关闭不全行主动脉瓣成形术的治疗进展. 中国胸心血管外科临床杂志, 2018, 25(2): 177-180.
4. Lansac E, Lim HS, Shomura Y, et al. A four-dimensional study of the aortic root dynamics. Eur J Cardiothorac Surg, 2002, 22(4): 497-503.
5. Spadaccio C, Nappi F, Al-Attar N, et al. Old myths, new concerns: the long-term effects of ascending aorta replacement with dacron grafts. Not all that glitters is gold. J Cardiovasc Transl Res, 2016, 9(4): 334-342.
6. Bentall H, De Bono A. A technique for complete replacement of the ascending aorta. Thorax, 1968, 23(4): 338-339.
7. 王春生, 李军, 赖颢. Stanford A 型主动脉夹层根部重建技术的应用现状与思考. 中华外科杂志, 2017, 55(4): 245-250.
8. Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol, 2017, 70(2): 252-289.
9. Etz CD, Bischoff MS, Bodian C, et al. The Bentall procedure: is it the gold standard? A series of 597 consecutive cases. J Thorac Cardiovasc Surg, 2010, 140(6 Suppl): S64-S70.
10. Kim TS, Na CY, Oh SS, et al. Long-term mortality and morbidity after button Bentall operation. J Card Surg, 2013, 28(3): 280-284.
11. Li K, Wang Q, Pham T, et al. Quantification of structural compliance of aged human and porcine aortic root tissues. J Biomed Mater Res A, 2014, 102(7): 2365-2374.
12. 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, 103(4): 617-621.
13. Pepper J, Yacoub M. Valve conserving operation for aortic regurgitation. J Card Surg, 1997, 12(2 Suppl): 151-156.
14. 孙立忠, 刘宁宁. 保留主动脉瓣的根部替换术 (David 手术). 中华胸心血管外科杂志, 2012, 28(9): 572-576.
15. Monsefi N, Zierer A, Risteski P, et al. Long-term results of aortic valve resuspension in patients with aortic valve insufficiency and aortic root aneurysm. Interact Cardiovasc Thorac Surg, 2014, 18(4): 432-437.
16. Bori Bata AK, D’Ostrevy N, Pereira B, et al. Valve-sparing aortic root replacement-midterm outcomes and quality of life. Cardiovasc Diagn Ther, 2017, 7(6): 572-580.
17. Svensson LG, Pillai ST, Rajeswaran J, et al. Long-term survival, valve durability, and reoperation for 4 aortic root procedures combined with ascending aorta replacement. J Thorac Cardiovasc Surg, 2016, 151(3): 764-774.
18. Urbanski PP, Lenos A, Irimie V, et al. Acute aortic dissection involving the root: operative and long-term outcome after curative proximal repair. Interact Cardiovasc Thorac Surg, 2016, 22(5): 620-626.
19. Yunoki J, Nakayama Y, Oonishi H, et al. Partial aortic root remodeling with an adventitial inversion technique for an acute type a aortic dissection. J Card Surg, 2010, 25(3): 327-329.
20. Fujimatsu T, Osawa H, Osaka S, et al. Strategies for treatment of acute aortic dissection with involvement of sinus of valsalva. Ann Thorac Cardiovasc Surg, 2009, 15(6): 382-388.
21. Huang F, Li L, Qin W, et al. Partial aortic root remodeling for root reconstruction in patients with acute type A dissection. J Biomed Res, 2016, 30(5): 411-418.
22. Fleischer KJ, Nousari HC, Anhalt GJ, et al. Immunohistochemical abnormalities of fibrillin in cardiovascular tissues in Marfan’s syndrome. Ann Thorac Surg, 1997, 63(4): 1012-1017.
23. Song HK, Preiss LR, Maslen CL, et al. Valve-sparing aortic root replacement in patients with Marfan syndrome enrolled in the National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions. J Heart Valve Dis, 2014, 23(3): 292-298.
24. Price J, Magruder JT, Young A, et al. Long-term outcomes of aortic root operations for Marfan syndrome: A comparison of Bentall versus aortic valve-sparing procedures. J Thorac Cardiovasc Surg, 2016, 151(2): 330-336.
25. Coselli JS, Weldon SA, Preventza O, et al. Valve-sparing versus composite root replacement procedures in patients with Marfan syndrome. Ann Cardiothorac Surg, 2017, 6(6): 692-696.
26. Semaan E, Markl M, Malaisrie SC, et al. Haemodynamic outcome at four-dimensional flow magnetic resonance imaging following valve-sparing aortic root replacement with tricuspid and bicuspid valve morphology. Eur J Cardiothorac Surg, 2014, 45(5): 818-825.
27. den Hartog AW, Franken R, Zwinderman AH, et al. The risk for type B aortic dissection in Marfan syndrome. J Am Coll Cardiol, 2015, 65(3): 246-254.
28. Lacro RV, Dietz HC, Sleeper LA, et al. Atenolol versus losartan in children and young adults with Marfan’s syndrome. N Engl J Med, 2014, 371(22): 2061-2071.
29. Biner S, Rafique AM, Ray I, et al. Aortopathy is prevalent in relatives of bicuspid aortic valve patients. J Am Coll Cardiol, 2009, 53(24): 2288-2295.
30. Tadros TM, Klein MD, Shapira OM. Ascending aortic dilatation associated with bicuspid aortic valve: pathophysiology, molecular biology, and clinical implications. Circulation, 2009, 119(6): 880-890.
31. Malvindi PG, Cappai A, Basciu A, et al. David operation: single center 10-year experience. J Cardiovasc Surg (Torino), 2015, 56(4): 639-645.
32. Losenno KL, Goodman RL, Chu MW. Bicuspid aortic valve disease and ascending aortic aneurysms: gaps in knowledge. Cardiol Res Pract, 2012, 2012: 145202.
33. Bavaria JE, Desai N, Szeto WY, et al. Valve-sparing root reimplantation and leaflet repair in a bicuspid aortic valve: comparison with the 3-cusp David procedure. J Thorac Cardiovasc Surg, 2015, 149(2 Suppl): S22-S28.
34. Loeys BL, Chen J, Neptune ER, et al. A syndrome of altered cardiovascular, craniofacial, neurocognitive and skeletal development caused by mutations in TGFBR1 or TGFBR2. Nat Genet, 2005, 37(3): 275-281.
35. Schepers D, Tortora G, Morisaki H, et al. A mutation update on the LDS-associated genes TGFB2/3 and SMAD2/3. Hum Mutat, 2018, 39(5): 621-634.
36. Sim HT, Seo DJ, Yu JJ, et al. Valve sparing aortic root replacement in children with Loeys-Dietz syndrome. Korean J Thorac Cardiovasc Surg, 2015, 48(4): 272-276.
37. Patel ND, Crawford T, Magruder JT, et al. Cardiovascular operations for Loeys-Dietz syndrome: Intermediate-term results. J Thorac Cardiovasc Surg, 2017, 153(2): 406-412.
38. Yamauchi H, Nawata K, Takeda N, et al. Abstract 20109: Midterm outcome of valve-sparing aortic root replacement in Loeys-Dietz syndrome. Circulation, 2018, 136: A20109.
39. Liu RH, Fraser CD 3rd, Zhou X, et al. Pseudoaneurysm formation after valve sparing root replacement in children with Loeys-Dietz syndrome. J Card Surg, 2018, 33(6): 339-343.
40. DeNino WF, Toole JM, Rowley C, et al. Comparison of David Ⅴ valve-sparing root replacement and bioprosthetic valve conduit for aortic root aneurysm. J Thorac Cardiovasc Surg, 2014, 148(6): 2883-2887.
41. Esaki J, Leshnower BG, Binongo JN, et al. Clinical outcomes of the David Ⅴ valve-sparing root replacement compared with bioprosthetic valve-conduits for aortic root aneurysms. Ann Thorac Surg, 2017, 103(6): 1824-1832.
42. Cho SH, Kim DH, Kwak YT. Valve-sparing root replacement: aortic root remodeling with external subvalvular ring annuloplasty. Korean J Thorac Cardiovasc Surg, 2016, 49(6): 489-492.
43. Lenoir M, Maesen B, Stevens LM, et al. Reimplantation versus remodelling with ring annuloplasty: comparison of mid-term outcomes after valve-sparing aortic root replacement. Eur J Cardiothorac Surg, 2018, 54(1): 48-54.
44. Andersen ND, Williams JB, Harrison JK, et al. Ascending-descending aortic bypass with valve-sparing root replacement for coarctation with aortic root aneurysm. J Thorac Cardiovasc Surg, 2012, 143(2): 514-515.
45. Yoneyama F, Okamura T, Harada Y, et al. Valve-sparing reimplantation for neoaortic root dilatation and regurgitation with an unbalanced cusp after the arterial switch operation. J Card Surg, 2018, 33(2): 122-125.
46. Izgi C, Nyktari E, Alpendurada F, et al. Effect of personalized external aortic root support on aortic root motion and distension in Marfan syndrome patients. Int J Cardiol, 2015, 197: 154-160.
47. Singh SD, Xu XY, Pepper JR, et al. Effects of aortic root motion on wall stress in the Marfan aorta before and after personalised aortic root support (PEARS) surgery. J Biomech, 2016, 49(10): 2076-2084.
48. Bauer M, Grauhan O, Hetzer R. Dislocated wrap after previous reduction aortoplasty causes erosion of the ascending aorta. Ann Thorac Surg, 2003, 75(2): 583-584.
49. Verbrugghe P, Verbeken E, Pepper J, et al. External aortic root support: a histological and mechanical study in sheep. Interact Cardiovasc Thorac Surg, 2013, 17(2): 334-339.
50. Treasure T, Takkenberg JJ, Golesworthy T, et al. Personalised external aortic root support (PEARS) in Marfan syndrome: analysis of 1-9 year outcomes by intention-to-treat in a cohort of the first 30 consecutive patients to receive a novel tissue and valve-conserving procedure, compared with the published results of aortic root replacement. Heart, 2014, 100(12): 969-975.
51. Austin C, Mathur SK, Pepper J. Personalised external aortic root support (PEARS): Utilisation in dilatational aortopathies after the arterial switch operation V4. Int J Cardiol, 2016, 220: 772-774.

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