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Ann Thorac Surg 2000;70:1465
© 2000 The Society of Thoracic Surgeons

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Discussion

Discussion

Discussion

DR AHMAD RAJAII KHORASANI (Neptune, NJ): I congratulate you for your excellent presentation.

Among different types of "valve-preserving" operations available for type A dissection, I have been interested in the one that maintains geometric morphology of the sinuses of Valsalva, namely David II type of operation. I believe this type of operation should provide a more durable valve due to preservation of the sinus space, which is important in reducing or eliminating the systolic trauma to the leaflets.

My limited clinical experience includes three cases that have been followed up for 5 years and their valve function has been normal. One of the patients had cardiac catherization at 4 years as part of the preoperative evaluation for repair of transverse and descending aneurysms. The valve function and the angiographic appearance of the aortic root was normal. The prosthetic sinuses had normal bulge. This patient underwent transverse arch replacement with elephant trunk operation. Unfortunately, the descending aorta ruptured before the descending aortic repair was done. At autopsy, the valve leaflets were normal and the morphology of the sinuses was normal.

My question is, what is your preferred valve-preserving operation and what is your opinion on valve durability in David I operation?

DR SCHÄFERS: Thank you for your question. If I understand correctly, you bring up the question of whether Coumadin might actually be beneficial to prevent clotting in the false lumen. In performing a Bentall operation, of course, you automatically place patients on Coumadin. I think this is a possibility in view of the late fate of aortic dissection, that is, potential dilatation, rupture, or secondary distal operations. It has been my thought that avoidance of Coumadin actually makes life easier for these patients.

I would agree with you that this is an early experience with this approach. However, I find the results with this approach very promising, and I think they are positive enough to be followed further.

DR JOSEPH E. BAVARIA (Philadelphia, PA): I just want to comment that this is a great series you have reported, but I echo the previous discussant’s opinions. We have just finished a North American, multicenter, investigational device exemption trial in which we studied 133 type A acute aortic dissections in the past 16 months alone. We went through some of the data preliminarily. Approximately 15% of the patients have a connective tissue disorder, and 10% to 15% have a bicuspid aortic valve; 70% of the patients who presented to these multicenter sites in the last 16 months had basically normal aortic root diameters.

It seems to me that if 70% of patients present to our operating rooms with basically normal diameter aortic roots, then we should try to preserve that "previously normal" root as much as possible and reserve the full root procedures for the 30% of type A dissections that really need it.

Additionally, when you do your supracoronary proximal anastomosis, do you do a separate resuspension?

Do you perform a "Tirone David type" procedure in which you select a graft diameter that would represent a normal sinotubular junction diameter for that patient and try to preserve the aortic valve with a supracoronary anastomosis and re-establishment of normal sinotubular junction anatomy?

DR SCHÄFERS: Can you repeat the first question again?

DR BAVARIA: The first question was how do you justify so many full aortic root procedures when 70% of acute Type A aortic dissection patients have a relatively normal root to begin with?

DR SCHÄFERS: I think this is a question that can be argued controversially. The question is what is a normal root? This question should be answered by prognosis in addition to site. I cannot give you the definite answer, and I am not aware of any information in the literature indicating that. It has been my thought and my personal observation that any root diameter (beyond 30 mm is more prone to secondary regurgitation in aortic dissection. And I think the 3 cases on which we had to reoperate indicate that further. So it appears that a sinotubular junction diameter of 35 or 40 mm is not normal.

Maybe to come to your second question regarding the David procedure and the technical aspects, what I have done is do the original David procedure, so valve reimplantation as originally described in 1992 and the diameter of the graft has been determined by height of the leaflet. In effect, I have not required a graft larger than 28 mm.

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