Kari Fabian A, Czerny Martin, Borger Michael, Misfeld Martin, Rylski Bartosz, Zimmer Emmanuel, Siepe Matthias, Hagl Christian, Detter Christian, Petersen Johannes, Richardt Doreen, Ensminger Stephan, Werner Paul, Andreas Martin, Peterss Sven, Pichlmaier Maximilian, Mueller Christoph S
Department of Cardiac Surgery, LMU University Hospital, Munich, Germany.
German Heart Center Munich, Technical University of Munich, Munich, Germany.
Eur J Cardiothorac Surg. 2025 Mar 4;67(3). doi: 10.1093/ejcts/ezaf034.
To define morphologic risk constellations during valve-sparing aortic root replacement (VSARR) for aortic valves with paracommissural fenestrations.
Patients from the multicentre prospective intention-to-treat VSARR-registry German Aortic Root Repair Registry (GEARR) were screened for paracommissural cusp fenestrations. We studied a combined end-point of residual aortic regurgitation (rAR) on post-cardiopulmonary bypass (CPB) transesophageal echocardiography (TEE), mid-term progress of rAR (transthoracic echocardiography) and aortic valve replacement for AR.
Of a total of 762 registry patients (operated 2016-2024), 145 were identified with ≥1 paracommissural cusp fenestration. Eighteen patients (12%) were not treated as planned but underwent composite valved graft (CVG) implantation. Mean follow-up time was 3 years. Upon post-CPB TEE, rAR grade 1 or 2 were present in 44 (33%) and 3 (2%) patients. 50% of patients with fenestrations in more than one cusp showed early progression of rAR. At 3 years, freedom from the combined end-point was 78% (99% CI 74-79%) for the complete study cohort. Patients with a maximum free margin length difference of <5 mm, reflecting balanced root anatomy with respect to sinus and cusp sizes, had a significantly better outcome than those with ≥5 mm: at 3 years, freedom from the combined end-point was 86% (99% CI 80-91%) vs 41% (99% CI 38-46%, P = 0.011). Outcome was worst for patients with cusp prolapse and a free margin length difference of >5 mm (30% vs 70%, P = 0.018).
Fenestrations in more than one cusp, inhomogeneities of cusp-free margin lengths, and additional prolapse are associated with inferior outcome after VSARR for valves with paracommissural fenestrations.
DRKS00007872.
明确保留瓣膜主动脉根部置换术（VSARR）治疗伴有瓣叶连合处开窗的主动脉瓣时的形态学风险组合。
对多中心前瞻性意向性治疗VSARR注册研究——德国主动脉根部修复注册研究（GEARR）中的患者进行瓣叶连合处瓣叶开窗筛查。我们研究了体外循环（CPB）后经食管超声心动图（TEE）检查时的残余主动脉反流（rAR）、rAR的中期进展情况（经胸超声心动图）以及因AR行主动脉瓣置换术的联合终点。
在总共762例注册患者（2016 - 2024年接受手术）中，145例被确定有≥1处瓣叶连合处瓣叶开窗。18例患者（12%）未按计划接受治疗，而是接受了带瓣复合移植物（CVG）植入。平均随访时间为3年。CPB后TEE检查时，44例（33%）患者存在1级或2级rAR，3例（2%）患者存在2级以上rAR。多个瓣叶有开窗的患者中，50%显示rAR早期进展。在3年时，整个研究队列达到联合终点的自由度为78%（99%CI 74 - 79%）。最大游离缘长度差异<5 mm的患者，即窦部和瓣叶大小方面根部解剖结构平衡，其结局明显优于最大游离缘长度差异≥5 mm的患者：在3年时，达到联合终点的自由度分别为86%（99%CI 80 - 91%）和41%（99%CI 38 - 46%，P = 0.011）。瓣叶脱垂且游离缘长度差异>5 mm的患者结局最差（30%对70%，P = 0.018）。
多个瓣叶开窗、瓣叶游离缘长度不均一以及额外的脱垂与伴有瓣叶连合处开窗的瓣膜行VSARR术后较差的结局相关。
DRKS00007872。
