Ann Thorac Surg 2005;80:843-844
© 2005 The Society of Thoracic Surgeons
Original article: Cardiovascular
Invited commentary
Michael J. Reardon, MD,
Jon-Cecil Walkes, MD
The Methodist DeBakey Heart Center, Texas Surgical Associates, 6560 Fannin St, 1002, Houston, TX 77030
(Email: mreardon{at}tmh.tmc.edu; jcwalkes{at}tmh.tmc.edu).
Cardiac surgeons have come to appreciate the cardiac valves as more than just leaflets and cusps, but rather complex functional units that interact with the heart. Preserving these functional units using valve repair techniques carries great appeal and has been widely adopted for mitral valve and tricuspid valve repair. In the atrial ventricular valves, repair techniques have been developed that are safe, reproducible, and durable. The ideal operation for aortic valve insufficiency would preserve the native aortic valve and as much of its functional unit comprised of the left ventricular outflow tract, the annulus, sinus of Valsalva, and sinotubular junction as possible. For aortic valve-conserving surgery to find wide use, the procedure will need to be accurately defined in technique and shown to be safe, effective, and durable. The two most common techniques used are the remodeling technique of Yacoub and the reimplantation technique of David. David and colleagues [1] have presented his series of 230 patients using reimplantation and remodeling techniques and shown an 8-year freedom from aortic insufficiency of 67%. This stratifies into a 90% freedom for reimplantation and a 56% freedom for remodeling. Yacoub and colleagues [2] have published their late results in 158 patients using Yacoub’s remodeling technique, with 33% of patients having mild or moderate aortic insufficiency and 3% having severe aortic insufficiency at follow-up up to 15 years. These patients had a 12% re-operation rate during this period for aortic insufficiency. Interestingly, he noted that most of his patients with significant aortic insufficiency had a fair amount of aortic insufficiency at the time of surgery and may represent inadequate repairs. This is reminiscent of what we learned in mitral valve repair. In a much smaller series for acute dissection comparing remodeling and reimplantation techniques, Leyh found a high failure rate for remodeling [3]. Therefore, the authors’ contention that there is no significant difference in the outcome between these two methods is open to question.
The article by Urbanski [4] describes a single patch replacement technique for all three sinuses, which is an extension of the three sinus patch technique used for supravalvular aortic stenosis described by Hazekamp and colleagues [5]. Along with techniques such as Albes and Wahlers’ [6] valve-sparing root reduction plasty, in which the sinuses are only plicated, represents another attempt at defining aortic valve-sparing surgery. All these approaches remain technically demanding and in need of greater definition to allow a more standardized approach and reproducible results. Valve surgeons have also learned that a follow-up period with a mean of 14.5 months is inadequate in predicting long-term results. I applaud the author on his innovative technique and good results and will look forward to the long-term follow-up as well as a more complete technical definition of how to size and shape the patches for the surgeon considering this approach.
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References
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- David TE, Ivanov J, Armstrong S, Feindel CM, Webb GD. Aortic valve-sparing operations in patients with aneurysms of the aortic root or ascending aorta Ann Thorac Surg 2002;74:1758-1761.
- Yacoub MH, Gehle P, Chandrasekaran V, Birks EJ, Child A, Radley-Smith R. J Thorac Cardiovasc Surg 1998;115:1080-1090.[Abstract/Free Full Text]
- Leyh RG, Fischer S, Kallenbach K, et al. High failure rate after valve-sparing aortic root replacement using the "remodeling technique" in acute Type A aortic dissection Circulation 2002;106(Suppl I):229-233.
- Urbanski PP. Valve-sparing aortic root repair with patch technique Ann Thorac Surg 2005;80:839-844.[Abstract/Free Full Text]
- Hazekamp MG, Kappetein AP, Schoof PH, et al. Brom’s three-patch technique for repair of supravalvular aortic stenosis J Thorac Cardiovasc Surg 1999;118:252-258.[Abstract/Free Full Text]
- Albes JM, Wahlers T. Valve-sparing root reduction plasty in aortic aneurysmthe "Jena" technique. Ann Thorac Surg 2003;75:1031-1033.[Abstract/Free Full Text]
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