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Ann Thorac Surg 2004;78:757
© 2004 The Society of Thoracic Surgeons
rkiliç, MDGülhane Military Medical Academy, Cardiovascular Surgery Department, Yazanlar Sokak No. 31/11, Asagi Ayranci, Ankara, Turkey 06540
e-mail: ekural{at}gata.edu.tr
To the Editor:
I read with great interest the article by Bauer and colleagues [1] and congratulate them on their excellent results. We do not understand why their experience is different from ours and most of the literature. We question their results. They stated that reduction aortaplasty showed good long-term results in patients with bicuspid aortic valve (BAV). In their experience redilation of the aorta occurred only in patients with suboptimal reduction in diameter.
Patients with BAV have pathology of the intrinsic aortic wall. Bauer and associates also reported a morphometric analysis of the aortic media in BAV patients and showed that the ascending aorta in patients with BAV has thinner elastic lamellae in the aortic media and a greater distance between elastic lamellae than that found in patients with a tricuspid aortic valve [2, 3].
Aortic dilatation is caused by abnormally high wall stress. Wall stress is directly proportional to the aortic diameter and inversely proportional to wall thickness and strength. Most BAV patients have dilatation of the ascending aorta. According to the Laplace rule, increased diameter increases wall stress. The conventional method to reduce wall stress to normal and to prevent rupture is to replace the aneurysmal aortic segment with a synthetic vascular prosthesis. Barnett and colleagues [4] advocated that reduction of the aortic diameter by a tailoring aortoplasty is a reasonable alternative to graft replacement in patients with ascending aortic aneurysm. Aortoplasty without external wall support effectively addresses one of the principal components of increased wall stress—the aortic diameter—but leaves the second equally important attribute—wall thickness and strength—unattended. Aortoplasty eliminates the aneurysm but does not prevent recurrence. Bauer and associates [1] concluded that reduction aortoplasty produced good long-term results in patients with BAV and dilatation of the aorta. According to our study [5], the ascending aorta tends to dilate after initial aortic valve replacement. The incremental rate of increase in the diameter of the ascending aorta was 1.25 mm per year in normotensive patients and 2.80 mm per year in hypertensive patients. Ascending aortic dilatation is prevented by external wrapping with Dacron material, which strengthens the ascending aortic wall.
We found that simple reduction aortoplasty may be effective for a dilated aorta at early and mid-term follow-up but that the ascending aorta will re-dilate because of weakness of the aortic wall. Therefore, reduction aortoplasty should be performed with external support to reduce the risk of re-dilatation. We have found aortic dilatation and aneurysm formation during follow-up in patients with normal-sized aortas at the initial aortic valve replacement operation. We have performed ascending aorta wrapping in BAV patients with normal-sized ascending aortas to avoid aneurysm formation. Russo and colleagues [6] have similar observations, and they advocate a more aggressive operation instead of wrapping.
References
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