N. Dobrilovic1,2, J. Fingleton2, A. Maslow2, W. Feng2, A. Singh2 1Northshore University Health System, Surgery, Evanston, IL, USA 2Brown University School Of Medicine, Surgery, Providence, RI, USA
Introduction:
Patients with aortic root aneurysm (and normal valve leaflets) can be treated with standard David operation. Today reimplantation surgery is a proven treatment with good long-term outcomes. However, the question remains: What to do when patients have severe aortic insufficiency with a significant component of aortic valve leaflet pathology… Repair or replacement?
Methods:
Between 1996 – 2016, 163 consecutive patients that underwent a David procedure were further scrutinized to identify those patients who required concomitant, complex valve leaflet repair in addition to David reimplantation. These 73/163 ‘complex valve repair’ patients are the subject of our study. Patients with a David remodeling procedure were excluded from this study. The study was conducted as a retrospective review of continuous patients at a single academic institution representing a 20+ year experience (1996 – 2016). Operative outcomes and long-term results were examined.
Results:
Mean age 45.1 (21 – 72) years; male 59 (80%); bicuspid 21 (29%); Marfan 18 (25%); other connective tissue disorder 6 (8%); acute type-A dissection 6 (8%). Size of aortic root (CT scan): 5.0-6.9 cm, mean 5.3 cm. All patients had grade 3+/4+ aortic regurgitation prior to surgery. Mean aortic cross-clamp time 127 (±21) minutes; Graft size mean 26 (24 – 30) mm; Type of graft: tube 17 (23%), Valsalva 56 (77%) pts; Associated procedures: CABG 4 (5%), MV repair 2 (3%), Arch replacement 3 (4%) pts. Valve leaflet anatomy observed intraoperatively: Number of prolapsed leaflets: one = 51 (67%), two = 12 (16%) pts, Multiple fenestrations: 14 (19%) pts, Valve leaflet repair techniques which were performed: Plication 45 (61%); Edge reinforcement/shortening 11 (15%); Patch with CorMatrix/pericardium 9 (12%); Commissural suture (Cabral) 8 (11%) pts. Operative mortality: There were no deaths (0%) in this group (73 pts). Patient follow up: mean 10 years, range 6 to 18. Sixteen (21%) patients had mild aortic regurgitation. Four (5%) patients had moderate aortic regurgitation, were asymptomatic, all had leaflet repair using CorMatrix. Freedom from moderate to severe aortic regurgitation: 93% over 10 yrs. Freedom from redo surgery: 97% over 10 yrs. One patient (connective tissue disorder) required redo valve replacement.
Conclusion:
The David procedure with concomitant complex valve leaflet repair for aortic root aneurysm is a durable procedure with excellent operative and long-term results. The patient’s native valve is preserved.