Surgery for mitral regurgitation in patients with aortic root aneurysm: Transaortic or transseptal approach?
OBJECTIVE
Mitral regurgitation is common in patients with aortic root aneurysm. Mitral valve repair (MVP) or replacement (MVR) can be performed for these patients through either a transverse aortotomy (TA) or transseptal approach (TS). This study sought to compare the early outcomes of mitral valve surgery through the TA and TS approaches and decide which is optimal for this subset of patients.


METHODS
Between March 2013 and April 2015, we operated on 99 patients (81 males, 81.8%) with aortic root aneurysm who developed mitral regurgitation. Mean age was 47.8±16.5years. MVR was performed in 66 patients (TAR=27; TSR=39) and MVP in 33 (TAP=8; TSP=25). The baseline and operative outcomes data were compared between patients with MVR and MVP through the TA vs TS approaches.


RESULTS
Preoperatively, the mitral regurgitation area was significantly larger in the MVR than MVP groups (8.9±2.0 vs 7.8±3.8 cm2, p=0.0009), and in the TSP vs TAP groups (8.5±4.1 vs 5.6±1.3cm2, p=0.0049), but no significant difference was found between the TAR and TSR groups (8.7±2.2 vs 9.0±1.8cm2, p=0.4681); the aortic sinus size was significantly larger in the TAR than TSR group (66.7±15.8 vs 52.1±8.8mm, p=0.0061). Subvalvular structure was preserved in 12 MVR patients (18.2%). In MVP patients, Kay annuloplasty was used in 11 (33.3%) and annuloplastic ring in 22 (66.7%). The times of cardiopulmonary bypass (CPB) and cross-clamp in patients with TA approach were significantly shorter compared to those with the TS approach (139±34 vs 176±38min, p=0.0001; 101±26 vs 129±31min, p=0.0002). No cases of mortality, stroke and renal failure occurred in the whole series. The amount of transfusion, lengths of ICU and hospital stay did not differ between patients with MVR and MVP, and between the TA and TS approaches.


CONCLUSIONS
Both the TA and TS approaches achieved good early outcomes in MV surgery for patients with root aneurysm. The transverse aortotomy was associated with shorter CPB and cross-clamp times. Surgical approaches should be selected according to the underlying mitral valve etiology and the size of the aortic root.
Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China; Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China; Beijing Lab for Cardiovascular Precision Medicine, Beijing, China; Key Laboratory of Remodeling-related Cardiovascular Disease, Ministry of Education, Beijing, China; Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China; Beijing Engineering Research Center for Vascular Prostheses, Beijing, China.
Wen-Jian
WJ
Jiang
Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China; Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China; Beijing Lab for Cardiovascular Precision Medicine, Beijing, China; Key Laboratory of Remodeling-related Cardiovascular Disease, Ministry of Education, Beijing, China; Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China; Beijing Engineering Research Center for Vascular Prostheses, Beijing, China.
Wei-Guo
WG
Ma
Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China; Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China; Beijing Lab for Cardiovascular Precision Medicine, Beijing, China; Key Laboratory of Remodeling-related Cardiovascular Disease, Ministry of Education, Beijing, China; Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China; Beijing Engineering Research Center for Vascular Prostheses, Beijing, China.
Xiao-Long
XL
Wang
Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China; Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China; Beijing Lab for Cardiovascular Precision Medicine, Beijing, China; Key Laboratory of Remodeling-related Cardiovascular Disease, Ministry of Education, Beijing, China; Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China; Beijing Engineering Research Center for Vascular Prostheses, Beijing, China.
Yu-Yong
YY
Liu
Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China; Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China; Beijing Lab for Cardiovascular Precision Medicine, Beijing, China; Key Laboratory of Remodeling-related Cardiovascular Disease, Ministry of Education, Beijing, China; Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China; Beijing Engineering Research Center for Vascular Prostheses, Beijing, China.
Jun-Ming
JM
Zhu
Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China; Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China; Beijing Lab for Cardiovascular Precision Medicine, Beijing, China; Key Laboratory of Remodeling-related Cardiovascular Disease, Ministry of Education, Beijing, China; Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China; Beijing Engineering Research Center for Vascular Prostheses, Beijing, China. Electronic address: lizhongsun@outlook.com.
Li-Zhong
LZ
Sun
Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China; Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China; Beijing Lab for Cardiovascular Precision Medicine, Beijing, China; Key Laboratory of Remodeling-related Cardiovascular Disease, Ministry of Education, Beijing, China; Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China; Beijing Engineering Research Center for Vascular Prostheses, Beijing, China. Electronic address: zhanghongjia722@ccmu.edu.cn.
Hong-Jia
HJ
Zhang
D000328:Adult; D001011:Aorta / Q000601:surgery*; D001014:Aortic Aneurysm / Q000150:complications / Q000175:diagnosis / Q000503:physiopathology; D001021:Aortic Valve / Q000000981:diagnostic imaging / Q000473:pathology; D002681:China; D000066491:Clinical Decision-Making; D005260:Female; D006346:Heart Septum / Q000000981:diagnostic imaging / Q000601:surgery; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000379:methods; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000000981:diagnostic imaging / Q000601:surgery; D008944:Mitral Valve Insufficiency / Q000209:etiology / Q000503:physiopathology / Q000601:surgery; D010043:Outcome and Process Assessment, Health Care; D018579:Patient Selection
Aortic root aneurysm; Mitral regurgitation; Mitral valve surgery; Surgical strategy; Transseptal approach; Transverse aortotomy