Valve-Sparing: Aortic Root Replacement
January/February 2007
Until recently, patients with aneurysms of the aortic root and ascending aorta have undergone replacement of their entire aortic root apparatus as part of the surgical repair of their aneurysms. This has been true regardless of whether their aortic valve leaflets were normal or diseased. That meant patients were subjected to either life-long anticoagulation therapy (in those receiving a mechanical composite valve conduit) or limited durability (in those receiving a biologic valve replacement).
At the University of Pennsylvania Health System, we have been performing valve-sparing aortic root replacement for patients with aortic root and ascending aorta aneurysms. The advantage of this operation is the replacement of the aneurysm with preservation of the patient's native aortic valve. The procedure is successful and safe. In our series at Penn, we have had no deaths and no reoperations for failure of repair.
Criteria for Surgery
To us, this advance has emphasized the need to evaluate and intervene with aortic aneurysm patients early, before their aortic valve leaflets are irreversibly damaged. At present, our decision for surgical intervention is based primarily on the patient's maximum aortic diameter and the severity of the aortic valve insufficiency.
Surgery is indicated for patients who have:
- an aortic diameter of 5.5 cm or greater;
- an aortic diameter of 5.0 cm or greater with concomitant severe aortic valve insufficiency;
- an aortic diameter of 4.5 cm or greater, with either a connective-tissue disorder such as Marfan syndrome, or
- a strong family history of aortic catastrophe
Aortic insufficiency is not an absolute contraindication for valve-sparing aortic root replacement, providing the aortic valves are functionally normal. Often, aneurysmal dilatation and displacement of the commissures lead to aortic valve insufficiency. Pre-operative echocardiography often demonstrates normal leaflets with poor coaptation, resulting in a central regurgitant jet. Particularly in younger patients (typically those with Marfan syndrome) whose aortic leaflets are often normal, preservation of the native aortic valves is ideal.
Restoring the Sinuses of Valsalva and Normal Anatomy
In valve-sparing aortic root replacement, we reconstruct the aortic root apparatus while preserving the native aortic valve leaflets. First described in 1995, the original procedure involved the reconstruction of the aortic root apparatus with the use of a straight Dacron® graft. However, the sinuses of Valsalva are believed to be an important anatomic component of the aortic root apparatus.
Recent data has suggested that coronary flow is improved and leaflet stress is reduced with the recreation of the sinuses of Valsalva. Therefore, to reconstruct the native aortic root with the optimal hemodynamics and leaflet durability, we use a Dacron graft conduit with pre-constructed sinus segments (“Valsalva” graft, Sulzer Vascutek, Refrewshire, Scotland). Preliminary results with this modification of the standard technique are encouraging.
In the past, bicuspid aortic valve was considered a contraindication for valve-sparing aortic root replacement. However, preliminary data suggests that even patients with a bicuspid valve (that is otherwise functionally normal) may be candidates for the valve-sparing procedure. We are evaluating the durability of this type of repair for such patients.
Thus, valve-sparing aortic root replacement allows patients to avoid life-long anticoagulation therapy and retain the durability of their native valves. Physicians should consider it for any patient who meets the appropriate criteria.
Article written by: Wilson Y. Szeto, MD and Joseph E. Bavaria, MD
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