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Ann Thorac Surg 2001;72:1508
© 2001 The Society of Thoracic Surgeons

Invited commentary

^a Department of Cardiothoracic Surgery, Mount Sinai Medical Center, Box 1028, New York, NY 10029, USA

e-mail: jan.galla{at}mssm.edu

The authors have provided an insightful presentation of their experience in the management of diseases of the aortic root in the patient with Marfan’s syndrome, extending over a period of 26 years. Within this timeframe, the authors have seen and adopted various new techniques, materials, and protocols that have helped them to generate a most enviable set of results.

Few in the thoracic community would argue with the difficulties encountered in managing diseases of the aortic root: The patient with an inherited connective disorder such as the Marfan’s syndrome makes this difficult situation all the more challenging. With the development of the classic Bentall repair and its subsequent modification by Kouchoukos, as well as others, the management of aortic root disease became a readily reproducible, acceptable-risk reality. The introduction of coated Dacron grafts and blood conservation techniques has minimized transfusion requirements and direct reattachment of the coronary arteries has all but eliminated the development of coronary artery pseudoaneurysm formation, thus tremendously reducing the two primary complications of aortic root reconstruction. The authors herein demonstrate that the results obtained at such premiere institutions as The Johns Hopkins Hospital are now readily within the reach of the practitioner.

Several issues detailed by the present authors deserve special attention and offer material for future investigations. While attractive for the lack of long-term anticoagulation, the use of homografts and valve sparing root reconstructions in the Marfan’s patient remains a hotly contested issue. Questions regarding the degree of involvement of the aortic valve leaflets with the connective tissue defect in Marfan’s syndrome are still argued in the literature, and data supporting either the preservation or removal of the entire valve can be found. While the valve is removed in the homograft reconstruction technique, the durability of the repair over the remainder of the patient’s life is also questioned. Increasingly, the trend seems to favor valved conduit repairs, accepting a lifetime need of anticoagulation. If newly collected data regarding the need for less and less, even to the point of no, anticoagulation of aortic mechanical prostheses holds up to further scrutiny, further discussion regarding the reconstruction method of choice may become moot.

Timing of interventions for root reconstruction in the Marfan’s patient appears to be coming to a more universal consensus. As the authors indicate, earlier intervention (at 4.5 cm or less) is indicated for high-risk patients, including those with strong family histories or rapid rates of progression. For prophylactic procedures, the author’s recommendation of 5 cm is prudent.

Finally, the authors further point out the need for continued, lifelong surveillance of the Marfan’s patients’ aortas. Although excellent results in root reconstruction are routinely available, the native aortic remnant remains afflicted with the underlying disorder and the potential for further aortic reconstruction remains real. The recommendations of the authors to follow their patients serially with annual computed tomography or magnetic resonance imaging for life is a practice that should be mandatory for those who engage in care of these patients.

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Jan D. Galla Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Galla, J. D. Search for Related Content PubMed Articles by Galla, J. D.