doi:10.1016/j.athoracsur.2004.03.040   
Copyright © 2004 The Society of Thoracic Surgeons. Published by Elsevier Inc.

Hawley H. Seiler Resident Award Paper

Results of aortic valve-sparing operations: Experience with remodeling and reimplantation procedures in 65 patients

Presented at the Fiftieth Annual Meeting of the Southern Thoracic Surgical Association, Bonita Springs, FL, Nov 13–15, 2003. *Recipient of the 2003 Hawley H. Seiler Resident Award.  

Brian T. Bethea MD^a, Torin P. Fitton MD^a, Diane E. Alejo BA^a, Christopher J. Barreiro MD^a, Stephen M. Cattaneo MD^a, Harry C. Dietz MD^b, Philip J. Spevak MD^c, Joao A. C. Lima MD^d, Vincent L. Gott MD^a and Duke E. Cameron MD<sup>a

a</sup> Division of Cardiac Surgery, Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
^b Howard Hughes Medical Institute, Chevy Chase, USA
^c Division of Pediatric Cardiology, Baltimore, MD, USA
^d Division of Adult Cardiology, the Johns Hopkins Medical Institutions, Baltimore, Maryland, USA

Accepted 16 March 2004.  Available online 26 August 2004.

Abstract

Background

Valve-sparing operations for aortic root aneurysms are increasing in frequency, but techniques and results are still in evolution. We reviewed our experience with 65 patients (adults and children) who had this operation at our institution to determine early and late outcomes.

Methods

A retrospective clinical review was undertaken using hospital records, clinical and echocardiographic, computed tomography, magnetic resonance imaging data, and telephone interviews with patients and their physicians.

Results

Between July 1994 and December 2002, 65 patients (46 adults and 19 children) underwent a valve-sparing operation for aortic root aneurysm. Forty-four of the patients had the Marfan syndrome; the remaining 21 had either a nonspecific connective tissue disorder (14 patients) or a miscellaneous disease process such as Ehlers-Danlos syndrome (7 patients). Fifty-eight (89%) had a David II (remodeling) procedure and 7 had a David I (reimplantation) procedure. The DePaulis "Valsalva graft" was used in six of the David I patients. There were no operative or hospital deaths; only one late death occurred in an adult due to salmonella meningitis. Overall, survival was 100% at one year and 98% at 3 and 5 years. Ten patients (7 adults and 3 children) developed significant late aortic insufficiency (AI). Nine of these patients had a David II procedure and in 8 of these cases, AI was secondary to significant late annular dilatation. One of the 10 patients developed late AI 8.2 years after a David I procedure; his AI was secondary to aortic leaflet extension and prolapse. Six of the 10 patients who developed significant late AI required aortic valve replacement (4 adults and 2 children). Freedom from late aortic valve replacement (AVR) in this series of 65 patients was 91% at 3 and 84% at 5 years. At the close of this study, 58 patients were New York Heart Association (NYHA) class I and 6 were NYHA class II; no patients were class III or IV. There were no episodes of endocarditis or clinically significant thromboembolism.

Conclusions

Valve-sparing operations provide satisfactory results for many patients with an aortic root aneurysm, but the David II remodeling procedure has a greater risk of late annular dilatation and AI. The David I reimplantation procedure utilizing the DePaulis Valsalva graft may obviate this problem.

Corresponding author. Address reprint requests to Dr Gott, 618 Blalock Building, The Johns Hopkins Hospital, 600 N Wolfe St, , Baltimore, MD 21287, USA