Aortic Valve Repair with Ring Annuloplasty and Selective Sinus Remodeling for Acute Type A Aortic Dissection

J. Baker¹, A. Singhal², T. James³, G. Stavridis⁴, A. Perez-Tamayo⁵, L. Wei⁶, V. Badhwar⁶, J. Scott. Rankin^6
1Missouri Baptist Medical Center, St. Louis, Missouri ²University of Iowa Hospitals and Clinics, Iowa City, Iowa ³Franciscan Cardiothoracic Surgical Associates, Tacoma, Washington ⁴Onassis Cardiac Surgey Ctr., Glyfada, Ioannina ⁵Hines VA Hospital, Chicago, Illinois ⁶West Virginia University, Morgantown, West Virginia

Purpose: Acute Type A aortic dissections often are complicated by aortic insufficiency (AI), and current surgical techniques have a modest incidence of AI recurrence and/or late sinus dilatation. To address this problem, we report the first series of acute Type A dissections managed with geometric ring annuloplasty plus selective sinus remodeling.

Methods: Forty-five consecutive patients with a variety of proximal dissection pathologies and moderate to severe AI were operated between October 2018 and December 2022. Average age was 58.4±15.5 years (mean±SD), male gender was 30/45 (67%), average preoperative AI Grade was 3.0±1.0, and NYHA Class was 2.6±1.3. Pre-repair annular diameter was 24.6±2.5 mm. Annuloplasty ring size was determined as leaflet free-edge length/1.5, and ring size averaged 21.9 ±1.9. All valves were tri-leaflet, and a minority (9-patients) required additional leaflet procedures. Average aortic graft size was 27.8±2.0 mm, hemi-arch or complete arch replacement was performed in 33/45 (73%), and 16/45 (36%) had frozen elephant trunks. Fifteen patients had preoperative cerebral malperfusion, requiring specific vascular grafts.

Results: Recovery of AI was excellent (Figure 1), from Grade 3.0±1.0 preoperatively to 0.2±0.4 after repair (p < 0.0001). Average post-repair mean systolic valve gradient was 9.5±4.5 mmHg. Selective remodeling graft replacement of dissected sinuses was performed in 26/45 (58%): 20=one sinus, 2=two sinuses, and 4=three sinuses. Cardiopulmonary bypass, aortic cross-clamp, and antegrade cerebral perfusion times were 193±68, 147±39, and 22±16 minutes, respectively. All 45 patients survived the procedure without new strokes, renal failure, or 30-day/in-hospital deaths. One post-discharge death occurred after 45-days in a Marfan patient with known cardiomyopathy (preoperative EF=15%), despite normal valve function. No patient required re-intervention on the aortic valve, although reoperation for washout and closure after coagulopathy was common. One patient required carotid graft revision, and another thoracic endo-grafting for rapid descending aortic dilation. All patients were doing well at an average of 18.9±12.1 months postoperative (max 53 months). Interval echocardiograms were obtained in 33/45 (73%), and in this sample, AI Grade remained stable at 0.2±0.4.

Conclusion: This initial experience with aortic ring annuloplasty and selective sinus remodeling for correction and stabilization of valve geometry in proximal aortic dissection was favorable. AI reduction was excellent and valve gradients low. Early results demonstrate the safety and reproducibility of this approach, and wider application with longer follow-up seems indicated.

Identify the source of the funding for this research project: None