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Ann Thorac Surg 1999;68:257-259
© 1999 The Society of Thoracic Surgeons
a Department of Thoracic and Cardiovascular Surgery, Saga Medical School, Saga, Japan
Address reprint requests to Dr Kamohara, Department of Surgery, Saga Medical School, Nabeshima-5-1-1, Saga, 849 Japan
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A 62-year-old woman was diagnosed with type-A acute aortic dissection complicated with cardiac tamponade and severe AR on June 24, 1995, and emergency surgery was performed on the same day. The operation was performed using cardiopulmonary bypass and cardioplegic arrest followed by aortic cross-clamping. An ascending aorta dilated with a hematoma of 55 mm x 40 mm in size was found. Entry point was seen at the ascending aorta, where tears involved four fifths of the circumference. Dissection proximally proceeded to the commissure, the right and noncoronary sinuses of Valsalva, and the annulus of the aortic valve. No abnormal findings were apparent in the aortic valves. The extent of the dissection showed the need for the reconstruction of the aortic root, and the David method was used to spare the native valves because these cusps were kept intact. A Dacron fabric tube, size 28 mm, was chosen to be used as an artificial graft. After the reconstruction, the aortic cusps were well placed. Saline was infused into the graft, but no regurgitation to the left ventricle was observed. Reconstruction of the coronary artery was performed with the aortic button "Carrel patch" method. Distal anastomosis with a graft was conducted according to the open distal method under circulatory arrest. Aortic regurgitation was found to be slight with transesophageal echocardiography.
The postoperative course was uneventful, and postoperative angiography showed minimum AR. Transthoracic echocardiography was performed several times after the operation until discharge from the hospital, and it was found that the degree of AR remained at the same level. Pathologic findings of the excised aortic wall revealed changes consistent with medial necrosis. She recovered from the operation and has been followed up as an outpatient after discharge. In June 1996, about 12 months after the initial operation, a gradual progression of AR (3 to 4/4) was observed by echocardiogram. She often presented with symptoms of dyspnea. She underwent reoperation January 16, 1997, 17 months after the initial operation, and the aortic valve was replaced with a St. Jude Medical valve of 21 mm in the supra-annulary position. The valve cusps, which were thin and pliable at the initial operation, were found to be thickened and retracted at the second operation. Pathologic findings of resected cusps showed hyalin and myxoid degeneration characterized by marked fibrous hypertrophy of collagen fibers (Fig 1). No adverse events occurred during the operation. The patient was discharged from the hospital without any postoperative complications.
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On the other hand, lesser durability of the aortic valve occurs with this method, because tissue degeneration of the valve cusps can be accelerated. This may be supported chiefly by the fact that the eddy currents are lost with the destruction of Valsalva’s sinus, which plays an important role in the mechanism of the opening and closing of the aortic valve [2]. Loss of the sinus may result in the degenerative progression of the cusps, causing poor joining, excessive stress by the imbalance of load-sharing, and physical contact with the graft [3, 4]. From several points of view, this patient was considered a good candidate for the David method. In this patient with acute aortic dissection, the valves were kept intact. Because anticoagulant therapy was not required in this method, postoperative problems related to prosthetic valves were avoided and occlusion of the false lumen with clots was also expected. In this case, however, the intact cusps at the initial operation were significantly shortened and thickened only 17 months after the operation. Pathologic findings showed myxoid degeneration association with fibrous hypertrophy or hyalinization of collagen fibers. These factors were considered to have influenced the deterioration of the cusps.
Remodeling methods [5] have now been attempted to avoid such nonphysiologic conditions. In the remodeling method, Valsalva’s sinus is excised and the end of the sinus is sutured with a graft prosthesis. This method may provide better durability of the valve, because Valsalva’s sinus was reconstructed by an artificial sinus of the graft. However, the valve annulus, which is plicated and strengthened by the method, does not protect well against future dilatation of aortic annulus in annuloaortic ectasia. Thus, both reimplantation and remodeling techniques have their drawbacks. No long-term results from studies of the reimplantation method have been reported.
At our institution, after the experience with this patient, endoscopy has been established for observation of the aortic root to select a technique for the reconstruction of the aortic root [6]. For these results and the results of this study, the remodeling method should be adopted to patients without annuloaortic ectasia, whose main cause of AR is the dilation of the sinotubular junction related to the ascending aortic aneurysm. In contrast, the David method should be used to prevent the dilation of the annulus in patients with Marfan’s syndrome or annuloaortic ectasia, particularly in cases in which the degree of degenerative changes is not so severe. In patients with acute aortic dissection involving the large part of the root, the remodeling method may be chosen because aortic cusp suspension is ineffective to prevent persistent AR. In cases of AR relapses after reimplantation, aortic valve replacement can be performed in a relatively easy manner, although it depends on the degree of adhesion.
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