Ann Thorac Surg 2009;88:2072-2073. doi:10.1016/j.athoracsur.2009.06.106
© 2009 The Society of Thoracic Surgeons
Correspondence
Commissural Fenestrations Are Not Contraindication for Aortic Valve and Root Repair
Paul Urbanski, MD, PhD
Department of Cardiovascular Surgery, Cardiovascular Clinic Bad Neustadt, Salzburger Leite 1, Bad Neustadt, 97616 Germany
(Email: p.urbanski{at}herzchirurgie.de).
To the Editor:
I read with great interest the report by Reade and colleagues [1] regarding commissural aortic cusp fenestrations. I would like to comment on the authors' conclusion that a valve-sparing repair is contraindicated in cases of commissural fenestrations.
During the process of dilatation, the sinuses change their dimensions in the transverse as well as longitudinal axis, leading to a distalward movement of the commissures. Therefore, most patients with aortic root dilatation, especially those having relevant insufficiency of the tricuspid aortic valve, reveal pathologic changes of the aortic cusps with commissural fenestrations and alteration of the cusp-free margin. This pathomorphology is observed even in patients with slight aortic root dilatation of approximately 4 cm, especially in patients suffering hypertension. Among 56 patients with insufficiency of the tricuspid aortic valve, which I repaired during 2008, 13 patients (23%) revealed commissural fenestrations with cusp prolapse. In such patients, valve-sparing root repair alone does not make sense because it would not abolish the aortic insufficiency. The repair of the aortic cusp, with a pericardial patch, for example, is in such cases essential; however, it must be complemented by restoration of the root anatomy (Figs 1 and 2).
Although in many patients the root repair can be performed by repair of isolated sinuses [2], the complex repair of the aortic valve and root is undoubtedly a challenging one. On the other hand, the early and mid-term results are very good. Our prospective annual follow-up of patients operated on using the single patch technique allows us continuous assessment of the functional results in time. In the series of 150 consecutive patients operated on between 2000 and 2007, the actuarial freedom of relevant aortic insufficiency at 5 years was 97.2%.
View larger version (72K):
[in this window]
[in a new window]
|
Fig 1. Transesophageal echocardiograms of patients with severe (4+) aortic insufficiency caused by complex pathology of aortic root and valve: dilatation of sinuses, commissural fenestrations with alteration of cusp-free margin and cusp folding.
|
|
View larger version (62K):
[in this window]
[in a new window]
|
Fig 2. Transesophageal echocardiograms of the same patients after valve repair with pericardial patch and reconstruction of all sinuses using the single patch technique.
|
|
Even though complete aortic root replacement with a valve composite graft is a standardized procedure with satisfactory results, the complex repair of the aortic valve and the aortic root can be performed despite commissural fenestration, offering excellent results.
 |
References
|
|---|
- Reade CC, Szeto WJ, Bavaria JE. Aortic valve commissural fenestration due to sinus of valsalva dilatation Ann Thorac Surg 2009;87:646.[Free Full Text]
- Urbanski PP, Zhan X, Frank S, Diegeler A. Aortic root reconstruction using new vascular graft Interact CardioVasc Thorac Surg 2009;8:187-190.[Abstract/Free Full Text]
Top
References