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Ann Thorac Surg 1997;64:1564-1568
© 1997 The Society of Thoracic Surgeons

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Supplement: Cardiovascular Surgery: Then and Now

Aortic Root Aneurysms: Remodeling or Composite Replacement?

Division of Cardiovascular Surgery, The Toronto Hospital, University of Toronto, Toronto, Ontario, Canada

Abstract

Background. Patients with ascending aortic aneurysms often have aortic insufficiency due to dilatation of the aortic root. Although composite replacement of the aortic valve and ascending aorta has been the standard treatment, an aortic valve-sparing operation is feasible in patients with normal aortic valve leaflets.

Methods. From 1988 to 1996, 208 patients with ascending aortic aneurysms and aortic insufficiency were operated on. Aortic valve-sparing operations were performed in 101 patients: 70 men and 31 women with a mean age of 53 years (range, 14 to 82 years). Twenty-eight patients had the stigmata of Marfan's syndrome. Fifteen patients had acute and 8 had chronic type A aortic dissection. Coronary artery disease was detected in 19 patients and mitral regurgitation in 5. Two types of aortic valve-sparing operations were performed: remodeling of the aortic root with preservation of the aortic valve in 73 patients and reimplantation of the aortic valve in a tubular Dacron graft in 28. Patients were followed up from 3 to 108 months (mean, 31 months). Doppler echocardiographic studies were performed annually.

Results. There were two operative deaths. One patient had to have aortic valve replacement because of persistent aortic insufficiency. There were five late deaths; the actuarial survival rate at 6 years was 87% ± 5%. One patient required aortic valve replacement 2 years after the initial operation; the freedom from aortic valve replacement at 6 years was 97% ± 2%. There have been no thromboembolic or infective complications. Only 3 patients have moderate aortic insufficiency; the remaining patients have mild or no aortic insufficiency.

Conclusions. The midterm results of aortic valve-sparing operations have been excellent and justify their continued use in patients with aortic root aneurysms and normal or near-normal aortic valve leaflets.

Degenerative diseases of the aortic root are frequently associated with aortic insufficiency because of dilatation of the sinotubular junction, aortic annulus or both [1, 2]. Most of these patients have a trileaflet aortic valve, and the leaflets are usually normal in the early stages of the dilatation process. As the aortic root dilates, the stress on the aortic valve leaflets increases and they may become thinner and develop fenestrations and tears. The length of the base of an aortic leaflet is approximately one and one-half times longer than the length of its free margin. This relationship may be lost in patients with dilated aortic root because of elongation of the free margins of the leaflets. However, it has been my experience that the aortic leaflets are fairly normal in at least half of these patients at the time of operation. This is frequently the case in patients who are operated on primarily for the aneurysms of the aortic root and ascending aorta and less frequently in those who are operated on because of aortic insufficiency.

Until recently patients with aortic root aneurysms were treated with composite replacement of the aortic valve and ascending aorta with a valved conduit [3, 4]. However, if the aortic valve leaflets are normal, it is feasible to resect the aneurysm with preservation of the aortic valve and remodel the aortic root with a Dacron graft to restore normal aortic valve function [5–8].

This article is a review of my experience with aortic valve-sparing operations in patients with aortic root and ascending aorta aneurysms.

Patients and Methods

From May 1988 to December 1996, 208 patients underwent operation for ascending aortic aneurysm and native aortic valve insufficiency. Resection of the aneurysm with preservation of the aortic valve was performed in 101 patients and aortic valve replacement with separate or composite replacement of the ascending aorta was performed in 107. Table 1 summarizes the clinical data on patients who had aortic valve-sparing operations.

Table 2 summarizes the operative data. Two types of aortic valve-sparing operations were performed: remodeling of the aortic root or reimplantation of the aortic valve [7, 8]. These operations were performed using knowledge of the functional anatomy of the aortic root [6]. Dilatation of the sinotubular junction displaces the commissures outward and prevents the aortic leaflets from coapting, with resulting central aortic insufficiency [9]. Simple adjustment of the sinotubular junction diameter corrects the aortic insufficiency in these patients [9]. In my patients this was accomplished by replacing the ascending aorta with a tubular Dacron graft of diameter approximately 10% smaller than the average length of the free margins of the three aortic leaflets. The graft was sutured right at the sinotubular junction of the aortic root and the three commissures were spaced equidistantly in the graft (Fig 1). If the sinotubular junction was estimated to be less than 24 mm, I used a larger graft and tapered one of its ends to the desirable diameter before suturing it to the sinotubular junction. Twenty-two patients had replacement of the ascending aorta with remodeling of the sinotubular junction for correction of the aortic insufficiency; the sinuses were not replaced because they were normal or minimally dilated. These patients were older than 60 years of age, and half of them also had arch and descending thoracic aortic aneurysms.

View larger version (131K): [in this window] [in a new window]   Fig 1. . Remodeling of the sinotubular junction by replacement of the ascending aorta. (Reproduced with permission from David TE, Feindel CM, Bos J. Repair of the aortic valve in patients with aortic insufficiency and aortic root aneurysm. J Thorac Cardiovasc Surg 1995;109:345–52.)

View larger version (64K): [in this window] [in a new window]   Fig 2. . Remodeling of the aortic root with replacement of all three aortic sinuses. (Reproduced with permission from David TE. Remodeling the aortic root and preservation of the native aortic valve. Op Tech Cardiac Thorac Surg 1996;1:44–56.)

View larger version (73K): [in this window] [in a new window]   Fig 3. . Aortic annuloplasty in patients with annuloaortic ectasia. (Reproduced with permission from David TE. Remodeling the aortic root and preservation of the native aortic valve. Op Tech Cardiac Thorac Surg 1996;1:44–56.)

View larger version (85K): [in this window] [in a new window]   Fig 4. . Reimplantation of the aortic valve in patients with annuloaortic ectasia and aortic root aneurysm. (Reproduced with permission from David TE, Feindel CM, Bos J. Repair of the aortic valve in patients with aortic insufficiency and aortic root aneurysm. J Thorac Cardiovasc Surg 1995;109:345–52.)

Results

There were two operative deaths, both due to cardiac failure. One patient had persistent severe aortic insufficiency and required a composite replacement of the aortic valve and ascending aorta. Eleven patients had reexplorations of the mediastinum for bleeding. Three patients suffered a stroke (2 recovered completely), and 2 had perioperative myocardial infarction.

Patients were followed up from 3 to 108 months (mean, 31 months). There were five late deaths: one sudden, one due to cerebral bleed, and three unrelated to cardiovascular disease. Figure 5 shows the actuarial survival; it was 87% ± 5% at 6 years. Aortic valve dysfunction developed in the youngest patient in this group and necessitated aortic valve replacement 2 years after the initial operation. The freedom from aortic valve replacement was 97% ± 2% at 6 years (Fig 6). Table 3 shows the degree of aortic insufficiency preoperatively and at the latest Doppler echocardiographic study. Three patients had moderate aortic insufficiency: 2 of them have had moderate aortic insufficiency since the operation and it has not changed over the years. The third patient had only mild aortic insufficiency after the operation and it has progressed to moderate during the first year of follow-up without symptoms or an increase in the size of the left ventricle. Two patients who had dissecting aneurysms required replacement of the entire descending thoracic and abdominal aorta; 1 suffered permanent paraplegia. No patient has had infective endocarditis or a thromboembolic complication.

View larger version (15K): [in this window] [in a new window]   Fig 5. . Actuarial survival after aortic valve-sparing operations.

View larger version (15K): [in this window] [in a new window]   Fig 6. . Freedom from aortic valve replacement.

The native aortic valve should be preserved whenever possible because a perfect prosthetic aortic valve is yet to be developed. The principal determinant of successful aortic valve-sparing operations is the quality of the aortic valve leaflets. Preoperative transesophageal echocardiography can often determine the number and the quality of the aortic valve leaflets. If the leaflets are thin, pliable, and without prolapse and the regurgitant jet is central, they are usually of good quality and an aortic valve-sparing operation is feasible. Patients with aortic root diameter in excess to 60 mm and gross aortic insufficiency frequently have damaged leaflets, and composite replacement of the aortic valve and ascending aorta is often necessary. The final decision, however, can only be made intraoperatively after careful inspection of the aortic valve leaflets.

Sound knowledge of the functional anatomy of the aortic root is indispensable for surgeons who perform aortic valve-sparing operations. Several publications have dealt with this [10–15], and with the operative techniques [8].

I believe that patients with Marfan's syndrome are candidates for aortic valve-sparing procedures if their leaflets are normal. Because they often have annuloaortic ectasia, an aortic annuloplasty is necessary. I have performed aortic valve-sparing operations in 28 patients with Marfan's syndrome: remodeling of aortic root in 15 and reimplantation of the aortic valve in 13. There has been only one failure in a young patient who had a growth spurt of 35 cm over 2 years; the aortic valve became stenotic and incompetent as the leaflets enlarged inside of a relatively small Dacron tube.

The appropriateness of aortic valve-sparing operations in patients with Marfan's syndrome has been questioned because of the finding that the fibrillin is abnormal in the elastin of the aortic valve leaflets in these patients [4, 16]. These abnormalities are more severe in patients with Marfan's syndrome who are more than 20 years of age, but they are also present in normal patients more than 60 years of age without Marfan's syndrome. These findings suggest that abnormal fibrillin is a progressive disorder similar to the myxomatous disease of the mitral valve. The experience with mitral valve repair in patients with mitral valve prolapse indicates that fixation of the mitral annulus with a prosthetic ring prevents or delays the progression of the myxomatous changes in the leaflets, at least during the first two decades after the operation [17, 18]. I expect the same results after aortic valve-sparing operations. In addition, my clinical results with these operations have been excellent in carefully selected patients with Marfan's syndrome.

Both techniques of preserving the aortic valve (reimplantation and remodeling) in patients with aortic root aneurysms render the aortic valve competent. Reimplantation is a simpler and safer operation than remodeling of the aortic root but it eliminates the aortic sinuses. It has been postulated that the absence of sinuses of Valsalva may increase the mechanical stress on the leaflets and may adversely affect their durability [19]. Remodeling of the aortic root with creation of three artificial aortic sinuses addresses this issue, but only time will determine if this is important for leaflet durability.

The current indications for surgical intervention in the aortic root of asymptomatic patients are based on the diameter of the aortic root. Operation is usually indicated when the aortic root reaches 55 mm in diameter [20, 21]. If the aortic valve leaflets are normal by echocardiography and an aortic valve-sparing operation can be performed, a more aggressive approach may be justifiable, particularly in patients with Marfan's syndrome to prevent irreversible damage to the aortic valve leaflets.

In conclusion, the results of aortic valve-sparing operations have been excellent during the first 8 years of follow-up and justify their continued use.

Footnotes

Presented at Cardiovascular Surgery—Then and Now, University of Virginia Medical Center, Charlottesville, VA, April 26, 1997.

Address reprint requests to Dr David, 200 Elizabeth St, 13EN219, Toronto, ON, Canada M5G 2C4.

References

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Tirone E. David Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by David, T. E. Search for Related Content PubMed PubMed Citation Articles by David, T. E.