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REVIEW TOPIC OF THE WEEK

Aortic Valve Sparing in DifferentAortic Valve and Aortic Root Conditions

Tirone E. David, MD

ABSTRACT

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The development of aortic valve-sparing operations (reimplantation of the aortic valve and remodeling of the aortic root)

expanded the surgical armamentarium for treating patients with aortic root dilation caused by a variety of disorders.

Young adults with aortic root aneurysms associated with genetic syndromes are ideal candidates for reimplantation of the

aortic valve, and the long-term results have been excellent. Incompetent bicuspid aortic valves with dilated aortic annuli

are also satisfactorily treated with the same type of operation. Older patients with ascending aortic aneurysm and aortic

insufficiency secondary to dilated sinotubular junction and a normal aortic annulus can be treated with remodeling of the

aortic root or with reimplantation of the aortic valve. The first procedure is simpler, and both procedures are likely equally

effective. As with any heart valve-preserving procedure, patient selection and surgical expertise are keys to successful

and durable repairs. (J Am Coll Cardiol 2016;68:654–64) © 2016 by the American College of Cardiology Foundation.

T he term aortic valve-sparing operation (AVS)was introduced to describe an operative pro-cedure developed to treat aortic root aneu-

rysm whereby the aneurysmal sinuses are excisedand the native aortic valve is implanted inside atubular Dacron (DuPont, Wilmington, Delaware) graft(1). Other types of operations designed to preservethe native aortic valve in patients with aortic rootand ascending aortic aneurysms were incorporatedinto the same term (2). Two main types of AVS havebeen extensively used: reimplantation of the aorticvalve and remodeling of the aortic root (2). Reimplan-tation of the aortic valve is performed by detachingthe coronary arteries from the aortic root and excisingthe aneurysmal aortic sinuses, except for a few milli-meters of arterial wall that are left attached to theaortoventricular junction (aortic annulus). Next, theaortoventricular junction is freed from the surround-ing structures, and the aortic valve is reimplanted in-side a tubular (Dacron) graft by securing it below andabove the aortic annulus. The coronary arteries arereimplanted into their respective neoaortic sinuses,

m the Division of Cardiac Surgery, Peter Munk Cardiac Centre at Toronto

iversity of Toronto, Toronto, Ontario, Canada. Dr. David has reported tha

s paper to disclose.

nuscript received March 7, 2016; revised manuscript received April 14, 20

and the reconstructed aortic root is sutured to theascending aorta, as illustrated in Figure 1. David andFeindel (1) and David et al. (2) first described reim-plantation of the aortic valve. Remodeling of theaortic root is performed by detaching the coronary ar-teries and excising the aortic sinuses, as describedpreviously, and reconstructing the aortic root with atailored tubular Dacron graft with neoaortic sinuses,as illustrated in Figure 1. Sarsam and Yacoub (3) firstdescribed remodeling of the aortic root.

Numerous technical modifications were intro-duced to these operations. Reimplantation of theaortic valve into a tubular Dacron graft eliminates theaortic sinuses, and their absence causes the aorticcusps to open and close more rapidly than normal or,after the remodeling procedure, during the cardiaccycle (4–6). This increase in velocity probably aug-ments mechanical stress on the aortic cusps (5). Cre-ation of neoaortic sinuses during reimplantation ofthe aortic valve reduces the velocity of opening andclosing of the cusps, but velocity does not return tonormal with either type of AVS, probably because of

General Hospital, Toronto, Ontario, Canada; and the

t he has no relationships relevant to the contents of

16, accepted April 19, 2016.

AB BR E V I A T I O N S

AND ACRONYM S

AI = aortic insufficiency

AVS = aortic valve-sparing

operation

BAV = bicuspid aortic valve

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the stiffness of the Dacron graft (4,5). This knowledgeprompted surgeons to create neoaortic sinuses duringreimplantation of the aortic valve (7–10). This goalcan be accomplished by using a tubular Dacron graftslightly larger than needed and placing darts in thegraft in 3 equidistant areas, corresponding to thenadir of the aortoventricular junction and betweenthe commissures, as shown in the sketch in the upperright of Figure 1.

Commercially available Dacron grafts with aorticsinuses have been used for reimplantation of theaortic valve: the Gelweave Valsalva graft (VascutekLtd., Inchinnan, United Kingdom) and the Cardiorootgraft (Atrium Medical Corporation, Hudson, NewHampshire). Figure 2 shows a sketch of the GelweaveValsalva (the Cardioroot graft has a similar shape). Wehave not used these grafts because their sinuses arespherical, and we fear that they may deform theaortoventricular junction after reimplantation of theaortic valve and adversely affect the bending char-acteristics of the aortic cusps. The normal aortoven-tricular junction is cylindrical, and the aortic sinusesbulge from this cylinder, as shown in Figure 3. The

FIGURE 1 Aortic Valve-Sparing Operations

Reimplantation of the aortic valve is performed with a tubular graft or wit

the aortic root is performed by tailoring tubular Dacron to recreate the

sinuses and aortic annulus. Reprinted with permission from David et al.

scalloped shape of the aortoventricular junc-tion where each cusp is attached evolvesalong a single horizontal plane, and only acylinder can provide this geometric arrange-ment. Another problem with grafts withspherical sinuses is that the height of the si-nuses may not coincide with the height of the

native aortic valve commissures, thus creating othertechnical and anatomic problems.

Figure 4 shows an anatomically correct Dacrongraft with sinuses that is available in Europe (Uni-Graft W SINUS, Braun, Melsungen, Germany) (11,12). Astudy using 4-dimensional cardiac magnetic reso-nance imaging in patients who had reimplantation ofthe aortic valve into this graft showed fairly normalflows, with nearly physiological sinus vortex forma-tion and transvalvular pressure gradients (13). Thereis limited experience with this graft (11,12), andfurther studies are needed to ensure that it maintainsits geometric configuration after implantationbecause tubular Dacron grafts tend to increase indiameter with time, particularly in the ascendingaorta (14). This anatomically correct Dacron graft with

Reimplantation of the aortic valve

Remodeling of the aortic root

h a tailored graft to recreate the aortic sinuses, whereas remodeling of

aortic sinuses and suturing the Dacron to the remnants of the aortic

(15).

FIGURE 2 Dacron Graft With Sinuses

The shape of a Dacron graft with sinuses (Gelweave Valsalva,

Vascutek Ltd., Inchinnan, United Kingdom; and Cardioroot graft,

Atrium Medical Corporation, Hudson, New Hampshire). Note the

spherical shape of the sinuses.

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sinuses mimics the normal aortic root and may proveto be the ideal graft for reimplantation of the aorticvalve in patients with aortic root aneurysm.

Remodeling of the aortic root is physiologicallysuperior to reimplantation of the aortic valve, likelybecause remodeling preserves the aortic annulusmovements during the cardiac cycle (4). However, thelong-term results of this type of AVS have not been asgood as those seen with reimplantation of the aorticvalve in patients with aortic root aneurysms, partic-ularly when the aneurysms are associated with ge-netic syndromes and incompetent bicuspid aorticvalves (BAVs) (15–19). The reason for the higher fail-ure rate after remodeling of the aortic root is dilationof the aortoventricular junction, which may be pre-sent at the time of surgery or may occur late in thepost-operative course (20).

Figure 5 shows echocardiographic views of theaortic root 1 week after remodeling of the aortic root

and mitral valve repair in a patient with Marfan syn-drome and 19 years later. The aortoventricular junc-tion and reconstructed aortic sinuses dilated, causingsevere aortic insufficiency (AI) that necessitatedreoperation. Intraoperative recognition of the dilatedaortoventricular junction in the mid-1990s promptedus to add an annuloplasty to the remodeling proce-dure by suturing a Dacron band on the outside aorticroot, along its fibrous components of the left ven-tricular outflow tract, as illustrated in the lower rightof Figure 1 (21). This maneuver corrected annulardilation at the time of surgery, but it did not preventfuture dilation of the tissue between the annuloplastyband and the Dacron graft sutured above the aorticannulus (15). Some surgeons continue to use remod-eling of the aortic root with a complete circumferen-tial annuloplasty ring, even in patients with aorticroot aneurysm associated with genetic syndromes(22). There are no long-term data on this, but on thebasis of our experience, we believe that this type ofreconstruction does not provide stable aortic valvefunction in young adults with aortic root aneurysms.

Remodeling of the aortic root is an excellentoperation in older patients with ascending aorticaneurysm, secondarily dilated aortic sinuses, and anormal aortoventricular junction. In this subgroup ofpatients, remodeling is not likely to fail because theaortic annulus will not dilate after surgery. Somepatients with ascending aortic aneurysm and AI sec-ondary to a dilated sinotubular junction can besatisfactorily treated by replacement of the ascendingaorta and reduction of the diameter of the sinotubularjunction (as illustrated in Figure 6) or by replacementof 1 or 2 aortic sinuses (2,23–25).

Dilation of the sinotubular junction can causeelongation of the free margin of 1 or more aortic cuspsand the development of stress fenestrations along thecommissural areas. Correction of sinotubular junctiondilation during AVS may cause 1 or more cusps toprolapse. Cusp prolapse can be corrected by plicationof its central part along the nodule of Arantius withfine suture material. Cusps with large stress fenes-trations along the commissural areas may rupture andcause AI after AVS. By reinforcing the free margin ofthe cusp from commissure to commissure with adouble layer of fine Gore-Tex suture (WL Gore & As-sociates, Flagstaff, Arizona), the risk of cusp rupturecan be reduced (26).

Some surgeons argue that AVSs are complex oper-ations and not easily reproducible, and these in-vestigators have proposed techniques of wrappingthe aortic root aneurysm without resection to pre-serve the native aortic valve (27–29). One of thesetechniques, the “Florida sleeve,” is performed using

FIGURE 3 Anatomy of the Aortic Root

Photographs of a human aortic root showing the cylindrical shape of the aortoventricular junction. Courtesy Muresian Horia, MD, PhD,

Bucharest, Romania.

FIGURE 4 Dacron Graft With Anatomically Correct Sinuses

An anatomically correct Dacron graft with sinuses (Uni-Graft W

SINUS, Braun, Melsungen, Germany).

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cardiopulmonary bypass. The ascending aorta istransected immediately above the sinotubular junc-tion, and a Dacron graft with spherical sinuses(Figure 2) is wrapped around the dilated aortic root byincising it in the areas corresponding to the coronaryarteries; the graft is then secured at the base of theaortic root and sinotubular junction without excisingthe aneurysmal aortic sinuses (27,28). Another type ofwrapping of the dilated aortic root is known as PEARS(personalized external aortic root support), whereby acustom-made macroporous mesh, manufactured onthe basis of the patient’s aortic root, as well asascending aorta size and shape obtained by computedtomography, is secured around the aortic root andascending aorta (29). There are limited clinical dataon these wrapping procedures (28,29).

TIMING OF SURGERY IN PATIENTS

WITH AORTIC ROOT AND ASCENDING

AORTIC ANEURYSM

Indications for surgery for patients with aortic rootand ascending aortic aneurysms are largely contin-gent on the diameter of the aneurysm, except in BAV,in which AI may ensue before the diameter of theaneurysm reaches a threshold where the risk ofrupture and aortic dissection outweighs the risk ofsurgery. The risks of aortic dissection and aorticrupture depend on the diameter of the aneurysm andthe associated genetic abnormality. Thus correctmeasurement of the diameter of the aortic sinusesand ascending aorta is essential, particularly in

FIGURE 5 Echocardiographic Images After Remodeling of the Aortic Root

These echocardiographic images were obtained 6 days (A) and 19 years (B) after remod-

eling of the aortic root and mitral valve repair in a patient with Marfan syndrome. The

aortic annulus increased from 23 to 38 mm, and the aortic sinuses increased from 33 to 48

mm, with consequent development of severe aortic insufficiency.

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patients with aneurysm of the aortic root associatedwith certain syndromes, in which a few millimetersappear to affect the risk of dissection and rupture.Electrocardiogram-gated computed tomography pro-tocols are crucial in reducing motion artifacts of theaortic root and thoracic aorta, and they provide ac-curate measurements.

Although aortic root aneurysms may develop inpatients of any age, most occur during the second tofourth decades of life. The dilation starts at the aorticsinuses and expands into the sinotubular junction

and ascending aorta. These aneurysms are oftenassociated with genetic syndromes, such as Marfansyndrome, Loeys-Dietz syndrome, familial aneu-rysms, BAV, and others. However, many aortic rootaneurysms are not linked to a known geneticsyndrome.

Degenerative ascending aortic aneurysms occur inpatients in their fifth to seventh decades of life. Thedilation starts at the midportion of the ascendingaorta and expands proximally and distally. Thedegenerative process may involve the sinotubularjunction and the aortic sinuses. As the sinotubularjunction dilates, the aortic cusps are pulled outward,and AI ensues. Thus AI of various degrees is commonin these patients. Association with genetic syndromesis uncommon, and most aneurysms are idiopathic.Degenerative aneurysm of the ascending aorta iscommon in BAV, and it may involve any segment ofthe proximal aorta (root, ascending, and proximalarch, including the innominate artery).

Table 1 lists the more common conditionsencountered in clinical practice and the diameters atwhich surgery is recommended (30–32). Patients witha family history of aortic dissection should beconsidered for surgery before the aneurysm reachesthe sizes shown in Table 1.

The growth rates of ascending aortic aneurysm areoften exponential: the larger the aneurysm is,the greater is the expansion rate, ranging from0.8 mm/year for small aneurysms (<40 mm) to 1.6mm/year for large aneurysms (80 mm) (33). Thegrowth rates for aortic root aneurysms are usuallyhigher and more variable, depending on the associ-ated genetic syndrome (34,35).

PATIENT SELECTION FOR AORTIC

VALVE-SPARING OPERATIONS

Transesophageal echocardiography is the best imag-ing modality to determine reparability of the aorticvalve. All components of the aortic root should beexamined in multiple views, and the diameters of theaortic annulus, aortic sinuses, sinotubular junction,and cusp heights should be recorded. The aorticcusps are the most important components of theaortic root in determining whether an AVS is feasible.Normal or nearly normal cusps are ideal for AVS.Cusp heights are important because the cusps have toseal the aortic orifice and provide enough tissue foradequate cusp coaptation. In our experience, cuspheight <13 mm precludes a satisfactory repair inadults because the annulus would have to be reducedexcessively for adequate cusp coaptation. Althoughcusp height can be augmented with a pericardial

FIGURE 6 Correction of Dilation of the Sinotubular Junction

Remodeling of the aortic root with correction of sinotubular junction dilation and the effect on the aortic valve cusps.

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patch, the durability of this type of repair is probablyinferior to that of replacement of the aortic valvewith tissue valves.

Dilation of the sinotubular junction stretches thefree margins of the aortic cusps and can cause stressfenestration along the commissural areas and, insome cases, detachment of the cusp from itscommissure that preclude a satisfactory AVS. Dilationof the aortic annulus also causes structural damage tothe aortic cusps. As the aortic annulus dilates, thebase of the subcommissural triangles widens and

TABLE 1 Indications for Surgical Intervention on the Basis of the

Diameter of the Aortic Root or Ascending Aorta in DifferentConditions

Aneurysm Type and Conditions Diameter (mm)

Aortic root aneurysm

Marfan syndrome 50

Loeys-Dietz syndrome 42

Aneurysm-osteoarthritis syndrome 42

Transforming growth factor aneurysm 42

Familial aneurysm syndrome 50

Bicuspid aortic valve 50

Degenerative, nonfamilial aneurysm 55

Ascending aortic aneurysm

Degenerative, idiopathic 55

Bicuspid aortic valve 55

Atherosclerotic 55

the commissural heights decrease, thus reducing thecoaptation area and stretching and thinning theentire cusp. Early surgery prevents these irreversiblealterations in the cusps. Actually, it has been ourexperience that most cusps are normal or have min-imal structural changes when surgery is recom-mended on the basis of current guidelines (Table 1).Patients with excessively large aortic sinuses andsinotubular junctions (e.g., diameters >60 mm) oftenhave damaged aortic cusps.

In patients with BAV, in addition to themorphology and quality of the cusps, particularlythe conjoint cusp, the angle between the maincommissures is an important predictor of long-termdurability of isolated BAV repair and AVS (36).This information can be obtained pre-operativelyby echocardiography (36). BAV with 2 cusps, 2sinuses, and 2 commissures at approximately 180� isideal for AVS. However, most BAVs have 3 aorticsinuses, and the orientations of the 2 main commis-sures are at >120� to <180� angles, but the closerthey are to 180�, the better the long-term outcomewill be (36).

MATCHING THE AORTIC ROOT DISORDER TO

THE AORTIC VALVE-SPARING OPERATION

Older patients with ascending aortic aneurysm, AI,and normal aortic cusps are ideal candidates for

FIGURE 7 Correction of Dilation of the Sinotububular Junction and

Replacement of 1 Aortic Sinus

Remodeling of the aortic root, with correction of sinotubular junction dilation

and replacement of the noncoronary aortic sinus.

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remodeling of the aortic root. If the aortic sinuses aresymmetrical and the diameter is #45 mm, simplereplacement of the ascending aorta with a graft of asize that reduces the dilated sinotubular junctionback to normal re-establishes valve competence andreduces the dilation of the aortic sinuses when su-tured to sinotubular junction (Figure 6). Correction ofthe dilation of the sinotubular junction may cause 1or more cusps to prolapse if their free margins wereelongated. Shortening of the free margin by plicationalong the nodule of Arantius corrects this problem.Once everything is done, the aortic cusps shouldcoapt in the central portion of the aortic root, wellabove the nadir of the aortic annulus.

If only 1 aortic sinus is diseased (i.e., dilated,effaced, or dissected), it should be replaced with anappropriately tailored graft, as illustrated in Figure 7.If all 3 aortic sinuses are abnormal, a remodelingprocedure, as shown in Figure 1, can be done. As longas the aortic annulus is not dilated (e.g., #12 mm/m2)(37), remodeling of the aortic root is the ideal opera-tive procedure because it preserves annular motion.

When all 3 aortic sinuses must be replaced, there isnothing wrong with performing reimplantation of theaortic valve instead of remodeling of the aortic root,

even in patients with an ascending aortic aneurysmand a normal aortic annulus. However, remodeling isa faster and simpler operation than reimplantation.This is particularly important in patients who havemore extensive degenerative aneurysmal diseaseinvolving the ascending aorta, transverse arch, andthoracic and abdominal aorta, as in the so-calledmega-aorta syndrome, in whom a more extensiveoperation including the aortic root, ascending aorta,and transverse arch is needed.

Young patients with aortic root aneurysm shouldhave reimplantation of the aortic valve for the rea-sons described in the preceding paragraph. Whetherthe aortic valve should be implanted into a cylindricalDacron graft or into a graft with sinuses remainscontroversial because long-term follow-up data areavailable only for patients who had the valveimplanted inside a straight Dacron graft (15,16).However, the aortic sinuses facilitate closure of theaortic valve by creating eddies and currents betweenthe cusps and the aortic sinus wall. In addition, thenormal aortic root is elastic and compliant; it expandsand contracts during the cardiac cycle. Placing theaortic valve inside a rigid and noncompliant structureis certain to increase the stress on the cusps and mayshorten their durability (38). For these reasons, theanatomically correct graft with sinuses (Uni-Graft)(Figure 4) should provide the best geometricarrangement for the cusps and optimize their dura-bility after reimplantation of the aortic valve. How-ever, this contention is not yet supported by clinicalevidence.

Patients with a BAV are more likely to come tosurgical attention because of AI than because of thesize of the aortic aneurysm. If the aortic cusps arewell developed (thin, pliable, and with adequateheight), the AI is often caused by dilation of the aorticannulus and consequent prolapse of the conjointcusp. Simple correction of the cusp prolapse andsubcommissural plication to reduce the diameter ofthe aortic annulus have not provided lasting results(39). Surgeons from Belgium showed better clinicaloutcomes when these valves were treated with thereimplantation procedure because the operation re-duces and stabilizes the aortic annulus (19). Webelieve that their approach is appropriate if the aorticsinus diameters exceed 40 mm, but it seems anaggressive approach if the aortic sinuses are normal.In these patients, we prefer to combine cusp repairwith an external annuloplasty band to correct thedilated aortic annulus, similar to what is shown inFigure 1 (right lower image), but here again, there isno clear evidence of the superiority of one approachover the other.

CENTRAL ILLUSTRATION Aortic Valve-Sparing Operations

David, T.E. J Am Coll Cardiol. 2016;68(6):654–64.

Freedom from reoperation and freedom from moderate or severe aortic insufficiency after reimplantation of the aortic valve to treat aortic root aneurysm.

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AVS operations have also been performed in pa-tients with acute type A aortic dissection. Surgery foracute aortic dissection remains challenging andhumbling, even to experienced surgeons, and it con-tinues to be associated with high rates of operative

mortality and morbidity (40). Adding a complexreconstruction of the aortic root at the time of surgeryfor acute dissection, which is primarily intended tosave the patient’s life, may not be the best approach,except perhaps in the hands of experienced aortic

TABLE 2 Freedom From Reoperation in the Aortic Valve and Freedom From Moderate or Severe Aortic Insufficiency After

Aortic Valve-Sparing Operations

First Author (Ref. #) n Mean Age (yrs) Marfan Syndrome BAV Mean Follow-Up (yrs)

Freedom From Adverse Events

Time Reoperation AI No. at Risk

Reimplantation of the aortic valve

David et al. (47) 296 46 36% 11% 6.9 5-yr 99.7% 98.3% 171

10-yr 97.8% 92.9% 62

15-yr 97.8% 89.4% 21

Liebrich et al. (48) 236 56 12% 15% 4.5 5-yr 94% 94% 78

10-yr 87% 91% 3

Shrestha et al. (49) 126 57 21% 4% 10 5-yr 91% N/A 97

10-yr 86% N/A 39

Kvitting et al. (50) 233 w38 40% 27% 4.7 5-yr 98% 97.4% w99

10-yr 92.2% 95.3% 18

De Paulis et al. (51) 124 53 17% N/A 5.2 5-yr 95.4% 94.1% 56

10-yr 90.1% 87.1% 23

Remodeling of the aortic root

Yacoub et al. (52) 158 46 43% N/A 5.5 5-yr 89% N/A N/A

10-yr 89% N/A N/A

Aicher et al. (53) 193* 62 N/A 0 4.0 5-yr 95% 88% 63

10-yr 95% 87% 5

81† 52 N/A 100% 4.0 5-yr 97% 96% 36

10-yr 97% 96% 1

*Tricuspid aortic valve. †Bicuspid aortic valve.

AI ¼ aortic insufficiency; BAV ¼ bicuspid aortic valve; N/A ¼ data not available.

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surgeons. Both types of AVSs have been used in thesepatients, but most surgeons believe that reimplanta-tion provides better outcomes than remodeling inpatients with acute type A aortic dissection (16,41).

Dilation of the pulmonary autograft is the principalmode of failure of the Ross procedure. The pulmonaryautograft valve can be saved by means of an AVS ifthe cusps have no degenerative changes (42). Hereagain, both types of AVS can be used, but becauseannular dilation is common after the Ross procedure,reimplantation of the aortic valve provides a morestable repair. Reoperations on patients with failedRoss procedures are complex, and adding a newcomplex operation should be done judiciously, incarefully selected patients. We believe that onlyentirely normal pulmonary autograft cusps should besaved by means of an AVS.

Older children and young adults who have hadcorrection of congenital heart defects, particularlydefects related to conotruncal lesions, may developprogressive dilation of the aortic root and also may betreated by means of AVS (43).

CLINICAL OUTCOMES OF

AORTIC VALVE-SPARING OPERATIONS

Elective AVS operations are associated with lowoperative rates of mortality and morbidity (16,43).

The operative mortality rate for elective proceduresshould be #1% (16,44). A report from The Society ofThoracic Surgeons database indicated that from 2004to early 2010, a total of 1,918 patients underwent AVSin the United States, and the overall mortality ratewas 1.9%, including urgent cases, the lowest of allaortic root operations (45).

In our experience, long-term survival after AVS issimilar to that of the general population matched forage and sex when patients with acute type A aorticdissections are excluded (15,16). Investigators haveshown that replacement of the aortic root and prox-imal aorta in patients with aortic root aneurysmsassociated with genetic syndromes does not preventdistal aortic dissections, but the risk is relatively low(15,46). These patients require continued surveillanceafter AVS and lifelong treatment with a beta-blocker.

The main problem with AVS is the development ofAI after surgery and the need for reoperation of theaortic valve. Because AI after AVS is “native valve AI,”many clinicians do not refer the patient back to thesurgeon for reoperation until symptoms or signs ofventricular dysfunction develop. Thus clinical reportsmade solely on the basis of freedom from reoperationas a measure of successful AVS must be interpretedwith caution. In addition, most series on outcomes ofAVS included patients with various disorders, and theresults may not represent what actually happens after

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surgery for each pathological entity. In addition,there are only a few reports on outcomes beyond10 years. The Central Illustration shows the rates offreedom from reoperation and freedom from moder-ate or severe aortic insufficiency after reimplantationof the aortic valve in our hospital (47). Table 2 sum-marizes the rates of freedom from reoperation andthe freedom from moderate or severe AI after AVS inselected reports (47–53).

We have learned much about AVS and believe thatwe are able to predict the durability of these opera-tions on the basis of pre-operative images and intra-operative findings. Reimplantation of the aortic valveis much more commonly performed than remodelingof the aortic root, but it is more complicated. Un-doubtedly, the quality of the aortic cusps is the mostimportant factor in predicting durability of AVS. Webelieve that normal aortic cusps of young patientshave better adaptive mechanisms than do cusps ofolder patients after AVS, particularly after the reim-plantation procedure. Matching the size of the graft tothe size of the cusps is difficult, and it remains moreart than science because the surgeon must tailor thegraft to the aortic valve, rather than the valve to thegraft. Thus the execution of AVS operations, partic-ularly reimplantation of the aortic valve, is difficultbecause it alters all components of the aortic root,and technical errors are common (54). After comple-tion of an AVS, the aortic cusps must move freelywithin the reconstructed aortic root without touchingthe Dacron graft and coapt well above the level of thenadir of the aortic annulus (55,56).

CONCLUSIONS

AVS operations have been performed for more than 2decades, but only recently have surgeons been able tomatch the aortic root disorder to the operative pro-cedure correctly. Young adults with aortic root an-eurysms are best treated with reimplantation of theaortic valve. The creation of neoaortic sinuses or theuse of Dacron grafts with anatomically correct aorticsinuses may enhance the durability of the aortic valvecusps. Because annular dilation is often present inpatients with incompetent BAV, correction of annulardilation is important, and reimplantation of the aorticvalve may be the best option. Older patients withascending aortic aneurysm, AI secondary to dilationof the sinotubular junction, and a normal aorticannulus and cusps can be satisfactorily treated withremodeling of the aortic root, ranging from simpleadjustment of the sinotubular junction to replace-ment of all 3 aortic sinuses and correction of cuspprolapse. AVS operations are complex reconstructiveprocedures that require a minimum volume of pa-tients for a team to develop and maintain expertise.As with repair of other heart valves, these operationsare not easily reproducible.

REPRINT REQUESTS AND CORRESPONDENCE: Dr.Tirone E. David, Division of Cardiac Surgery, PeterMunk Cardiac Centre at Toronto General Hospital andthe University of Toronto, 200 Elizabeth Street,4N453 Toronto, Ontario M5G 2C4, Canada. E-mail:tirone.david@uhn.ca.

RE F E RENCE S

1. David TE, Feindel CM. An aortic valve-sparingoperation for patients with aortic incompetenceand aneurysm of the ascending aorta. J ThoracCardiovasc Surg 1992;103:617–21; discussion 622.

2. David TE, Feindel CM, Bos J. Repair of the aorticvalve in patients with aortic insufficiency andaortic root aneurysm. J Thorac Cardiovasc Surg1995;109:345–51; discussion 351–2.

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KEY WORDS aortic insufficiency, aorticroot aneurysm, aortic valve repair