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Correspondence

Reply

Department of Cardiothoracic Surgery, Wake Forest University School of Medicine, Winston-Salem, NC 27157

(Email: tkincaid{at}wfubmc.edu).

To the Editor:

We congratulate Dr D’Onofrio and his colleagues [1] on their excellent results with the inclusion technique for implantation of stentless porcine valves. We also used this technique early in our series [2], but quickly switched to near universal application of the total root replacement procedure. The primary reason for this switch was to achieve optimal hemodynamics, which has clearly been demonstrated by numerous authors using several types of aortic root prostheses implanted in different manners [3–6]. In addition, a recent long-term analysis of the Freestyle database revealed lower freedom from structural valve degeneration using the inclusion technique compared with subcoronary or total root implantation [7]. One possible anatomic explanation for this finding is that a low-lying, unmobilized right coronary artery can buckle the inflow portion of the prosthesis after anastomosis in the usual location.

Although not observed in D’Onofrio and colleagues’ series, pseudoaneurysm formation has historically been associated with all types of aortic surgery using the inclusion technique, and it remains a concern of ours, especially when constructing anastomoses in the presence of incompletely addressed sinus pathology. The total root procedure thus becomes the most flexible option to manage all forms of aortic root disease.

Do these advantages come at the expense of an increased incidence of coronary ischemia? We believe they do not, as there are certainly documented occurrences of right coronary obstruction, even with traditional stented aortic valve replacements in the absence of any coronary manipulation [8], and these episodes are probably under-detected and under-reported. Right coronary ischemia may easily be confused with other intraoperative and postoperative complications, and similar to so many other problems in medicine, the harder one looks, the more often they are found.

Currently, there is no perfect solution to the management of aortic valve disease, as suggested by the promotion of so many different operations by various surgical groups. Our preferences are based on some scientific evidence, but also on the desire to most closely recreate the anatomy that was bestowed on us by nature.

	References

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1. D’Onofrio A, Auriemma S, Magagna P, Abbiate N, Fabbri A. The inclusion technique reduces ischemia after stentless aortic root replacement(letter) Ann Thorac Surg 2008;85:1143-1144.[Free Full Text]
2. Kincaid EH, Cordell AR, Hammon JW, Adair SM, Kon ND. Coronary insufficiency after stentless aortic root replacement: risk factors and solutions Ann Thorac Surg 2007;83:964-968.[Abstract/Free Full Text]
3. Palka P, Harrocks S, Lange A, Burstow DJ, O’Brien MF. Primary aortic valve replacement with cryopreserved aortic allograft: and echocardiographic follow-up study of 570 patients Circulation 2002;105:61-66.[Abstract/Free Full Text]
4. Panos A, Amahzoune B, Robin J, Champsaur G, Ninet J. Influence of technique of coronary artery implantation on long-term results in composite aortic root replacement Ann Thorac Surg 2001;72:1497-1501.[Abstract/Free Full Text]
5. Matsue H, Sawa Y, Takahashi T, et al. Three-dimensional flow velocity quantification of Freestyle aortic stentless bioprosthesis by magnetic resonance imaging: surgical consideration Semin Thorac Cardiovasc Surg 2001;13:60-66.[Medline]
6. Luciani GB, Casali G, Barozzi L, Mazzucco A. Aortic root replacement with the Carboseal composite graft: 7-year experience with the first 100 implants Ann Thorac Surg 1999;68:2258-2262.[Abstract/Free Full Text]
7. Bach DS, Kon ND, Dumesnil JG, Sintek CF, Doty DB. Ten-year outcome after aortic valve replacement with the freestyle stentless bioprosthesis Ann Thorac Surg 2005;80:480-486.[Abstract/Free Full Text]
8. Salerno TA, Bergsland J, Calafiore AM, Cordell AR, Kon ND, Bhayana JN. Acute right ventricular failure during aortic valvular operation due to mechanical problem in the right coronary artery Ann Thorac Surg 1996;61:706-707.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map 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): Edward H. Kincaid Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Kincaid, E. H. Search for Related Content PubMed Articles by Kincaid, E. H. Related Collections Related Article