Introduction

Article Outline

• Stentless Xenograft Implantation: Free-Standing Root or Subcoronary?
• Biological versus Mechanical Pulmonary Valve Replacement
• Surgical Approaches to Gastroesophageal Reflux Disease
• Copyright

This issue continues our format of point/counterpoint with a few variations. In the Cardiac Surgery section we present the same device inserted by three different techniques, and in the Congenital Surgery section, for the first time, we publish one of the very popular debate topics from the 86th Annual Meeting of the American Association for Thoracic Surgery in Philadelphia, argued by Drs. Dearani and Brown and moderated by Dr. John Lamberti of San Diego.

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Stentless Xenograft Implantation: Free-Standing Root or Subcoronary? 

Stentless xenografts continue to generate interest as a bioprosthetic valve option, offering possibly improved hemodynamics with an off-the-shelf device. Neil Kon, Donald Doty, and Michael Deeb were among the earliest adopters of this technology for aortic valve replacement. Each of these surgeons, however, implants the prostheses in a slightly different manner. Their techniques are well illustrated, allowing the reader to compare each approach and select among them. Neil Kon is an advocate of the freestanding root as a means of achieving the greatest possible hemodynamic benefit from aortic valve replacement. Donald Doty has a slightly different approach, with a running proximal anastomosis that speeds the conduct of the operation along a bit. His contribution also highlights specific applications of the stentless root in the management of proximal aortic pathologic conditions, and Michael Deeb describes the subcoronary implantation of the stentless xenograft, again with detailed explanations of techniques he uses to deal with particular anatomic challenges. Taken together, these three contributions provide a broad view of alternative techniques for implantation of the stentless aortic valve.

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Biological versus Mechanical Pulmonary Valve Replacement 

Pulmonary valve replacement is being undertaken with increasing frequency as the population of late survivors of tetralogy of Fallot surgery ages. A number of controversies surround pulmonary valve replacement in this setting. Most importantly, the indications and timing for surgery remain unclear. The introduction of cardiac magnetic resonance imaging with the ability to measure right ventricular volume, function, and regurgitant fraction will assist in developing more objective criteria. Another important controversy addressed in this issue relates to the best type of valve prosthesis to be used in the pulmonary position. Although biological valves have traditionally been considered the valve of first choice, they can increase the risk of early calcific degeneration in this relatively young population. Dr. Joe Dearani from the Mayo Clinic has presented the alternative option of using a mechanical valve that has been applied successfully in a small percentage of patients at the Mayo Clinic. The traditional approach, namely, the use of a bioprosthesis, is presented by Dr. John Brown from Indiana. Dr. John Lamberti, who moderated this debate at the 2006 American Association of Thoracic Surgery Annual meeting in Philadelphia, summarizes his excellent conclusion of this debate.

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Surgical Approaches to Gastroesophageal Reflux Disease 

Gastroesophageal reflux disease is a benign condition that affects as many as 10% of North Americans. Although many surgical approaches have been proposed, this issue illustrates two distinct approaches to the treatment of benign esophageal disease. Drs. Teh and Hunter describe their technique for restoring the competency of the lower esophageal sphincter by Nissen fundoplication and gastroplasty. In contrast, Dr. DeMeester describes his approach to the replacement of the entire esophagus with interposed colon. Both approaches have merit and will be used by many general thoracic surgeons for different patient scenarios.