Over the last decade, valve-sparing aortic root reconstruction has evolved into an important technique in our surgical armamentarium for dealing with aneurysmal disease of the thoracic aorta. The technique was originally developed largely with Marfan syndrome in mind; however, it is now becoming clear that it has perhaps an even broader application among individuals with degenerative disease, bicuspid aortic valve disease with root dilation, and even acute aortic dissection. The early and mid-term results appear promising, although the true late durability will only be known in the fullness of time.
In broad terms, two approaches to the repair of such root aneurysms have developed. My own exposure to these techniques began in the early 1990s with the Yacoub technique. The details of this technique were provided by Professor Yacoub in the very first volume of Operative Techniques in Thoracic and Cardiovascular Surgery. His own results have been outstanding. Professor Yacoub’s method of excising the sinuses and replacing them with a scalloped graft using a single suture line above the surgical annulus permits great flexibility in establishing the heights of the commissural posts and creates full artificial sinuses of Valsalva, which are readily appreciable on postoperative studies. While the functional significance of such sinuses remains to be proven, they may be important for preventing contact of the fragile native leaflet against the Dacron graft during systole. At a minimum they are appealing from an esthetic basis and are, I feel, an important aspect of this procedure. The disadvantage of this technique is lack of stabilization of the diameter of the aortoventricular junction. Several authors have suggested dilation of the aortoventricular junction as a mechanism of late failure after the valve-sparing procedure.
A competing approach was developed essentially simultaneously and independently by Dr. Tirone David. Dr. David was also a contributor to the first issue of this journal and his original technique is described there as well. In this technique the entire aortic valvular apparatus is reimplanted within a Dacron tube graft. Accordingly, this technique involves two proximal suture lines, one beneath the aortic annulus and the other essentially subcoronary akin to the suture line used in free-hand homograft implantation. In addition to stabilizing the aortoventricular junction, this is a more readily hemostatic technique as intra-aortic and intraventricular pressure tend to seal the suture lines by pressing the aorta against the Dacron graft. The disadvantage of this technique has been less full development of sinuses of Valsalva.
A number of variations on David’s technique have been developed. A Dacron graft specifically designed to re-create sinuses of Valsalva is now commercially available and has found a number of ardent supporters. The technique we have found to be simpler and more economical is a two graft method as suggested by Dr. Craig Miller of Stanford University. We have been pleased with the application of this approach in all of the aforementioned settings including acute aortic dissection.
The described approach to valve re-implantation within a Dacron graft has proven a reliable technique for us in a variety of settings. We have been impressed that bleeding is minimal once the clamp is removed. The technique appears to be reliably guided by the use of universal sizers to determine and then reconstruct the desired annular and sinotubular dimension. We have not found a mathematical formula related to leaflet geometry to be useful as the pathologic anatomy itself is often abnormal. A valve that is competent within a greatly enlarged root, for example, may be rendered centrally incompetent by excessive reduction of the sinotubular dimension such that prolapse is created. The use of sizers and a two graft technique makes the approach reproducible in our experience. We have also been pleased with the neosinuses created. This technique has been a useful addition to our armamentarium and we use it frequently, selecting between this and the Yacoub reconstruction based on circumstances.
© 2005 Elsevier Inc. Published by Elsevier Inc.
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