Aortic Valve Reconstruction: Why, When, and How?

Abstract

After almost 20 years aortic root reconstruction modalities have evolved into reasonable and useful surgical measures. Short and long term results match those of aortic composite replacement. Three major restitution strategies have found widespread acceptance: Root replacement with valve reimplantation (David-Procedure), root remodeling (Yacoub-procedure), or commissural resuspension. In the wake of these modalities also isolated aortic valve repair techniques have found renewed interest in order to broaden the indication for reconstructive surgery. Some euphemistic and hence biased interpretation, however, should be considered when looking at the clinical results. Reimplantation and remodeling procedures as well as several valve repair maneuvers are technically demanding unfolding their potential only in the hands of an experienced surgeon. Definite guidelines regarding the appropriate method of restitution required to serve best in the patient’s individual situation are not yet at hand although they are about to emerge.

Key words

aortic valve - aortic root - aortic dissection - remodeling

References

• 1 Fazel S S, David T E. Aortic valve-sparing operations for aortic root and ascending aortic aneurysms.  Curr Opin Cardiol. 2007;  22 (6) 497-503
• 2 Gott V L, Gillinov A M, Pyeritz R E. Aortic root replacement: risk factor analysis of a seventeen-year experience with 270 patients.  J Thorac Cardiovasc Surg. 1995;  109 536-545
• 3 Sioris T, David T E, Ivanov J, Armstrong S, Feindel C M. Clinical outcomes after separate and composite replacement of the aortic valve and ascending aorta.  J Thorac Cardiovasc Surg. 2004;  128 260-265
• 4 Svensson L G, Deglurkar I, Ung J, Pettersson G, Gillinov A M, D'Agostino R S, Lytle B W. Aortic valve repair and root preservation by remodeling, reimplantation, and tailoring: technical aspects and early outcome.  J Card Surg. 2007;  22 (6) 473-479
• 5 David T E, Feindel C M. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta.  J Thorac Cardiovasc Surg. 1992;  103 (4) 617-622
• 6 Yacoub M H, Gehle P, Chandrasekaran V, Birks E J, Child A, Radley-Smith R. Late results of a valve-preserving operation in patients with aneurysms of the ascending aorta and root.  J Thorac Cardiovasc Surg. 1998;  115 (5) 1080-1090
• 7 Albes J M, Stock U A, Hartrumpf M. Restitution of the aortic valve: what is new, what is proven, and what is obsolete?.  Ann Thorac Surg. 2005;  80 (4) 1540-1549
• 8 El Khoury G, Vanoverschelde J L, Glineur D, Poncelet A, Verhelst R, Astarci P, Underwood M J, Noirhomme P. Repair of aortic valve prolapse: experience with 44 patients.  Eur J Cardiothorac Surg. 2004;  26 (3) 628-633
• 9 Cohen O, De La Zerda D J, Odim J, Dinov I, Laks H. Aortic valve-sparing repair with autologous pericardial leaflet extension has low long-term mortality and reoperation rates in children and adults.  Heart Surg Forum. 2007;  10 (4) E288-E291
• 10 De Kerchove L, Boodhwani M, Glineur D, Poncelet A, Rubay J, Watremez C, Vanoverschelde J L, Noirhomme P, El Khoury G. Cusp prolapse repair in trileaflet aortic valves: free margin plication and free margin resuspension techniques.  Ann Thorac Surg. 2009;  88 (2) 455-461
• 11 Miller D C. Valve-sparing aortic root replacement: current state of the art and where are we headed?.  Ann Thorac Surg. 2007;  83 (2) S736-S739
• 12 Erasmi A W, Sievers H H, Bechtel J F, Hanke T, Stierle U, Misfeld M. Remodeling or reimplantation for valve-sparing aortic root surgery?.  Ann Thorac Surg. 2007;  83 (2) S752-S756
• 13 Kallenbach K, Baraki H, Khaladj N, Kamiya H, Hagl C, Haverich A, Karck M. Aortic valve-sparing operation in Marfan syndrome: what do we know after a decade?.  Ann Thorac Surg. 2007;  83 (2) S764-S768
• 14 Hetzer R, Komoda S, Komoda T. Remodeling of aortic root by annular reconstruction and plication of sinuses of Valsalva.  J Card Surg. 2008;  23 (1) 49-51
• 15 Kollar A C, Lick S D, Conti V R. Valve-sparing aortic root reconstruction using in situ three-dimensional measurements.  Ann Thorac Surg. 2009;  87 (6) 1795-1800
• 16 Ruvolo G, Fattouch K. Aortic valve-sparing root replacement from inside the aorta using three Dacron skirts preserving the native Valsalva sinuses geometry and stabilizing the annulus.  Interact Cardiovasc Thorac Surg. 2009;  8 (2) 179-181 (Epub 2008 Nov 19)
• 17 Izumoto H, Kawazoe K, Kawase T, Kim H. Subvalvular circular annuloplasty as a component of aortic valve repair.  J Heart Valve Dis. 2002;  11 383-385
• 18 Cameron D E, Alejo D E, Patel N D, Nwakanma L U, Weiss E S, Vricella L A, Dietz H C, Spevak P J, Williams J A, Bethea B T, Fitton T P, Gott V L. Aortic root replacement in 372 Marfan patients: evolution of operative repair over 30 years.  Ann Thorac Surg. 2009;  87 (5) 1344-1350
• 19 Khaladj N, Leyh R, Shrestha M, Peterss S, Haverich A, Hagl C. Aortic root surgery in septuagenarians: impact of different surgical techniques.  J Cardiothorac Surg. 2009;  4 17
• 20 Volguina I V, Miller D C, LeMaire S A, Palmero L C, Wang X L, Connolly H M, Sundt 3rd T M, Bavaria J E, Dietz H C, Milewicz D M, Coselli J S. Aortic valve operative outcomes in Marfan patients study group. Valve-sparing and valve-replacing techniques for aortic root replacement in patients with Marfan syndrome: analysis of early outcome.  J Thorac Cardiovasc Surg. 2009;  137 (5) 1124-1132
• 21 Guntheroth W G. A critical review of the American College of Cardiology/American Heart Association practice guidelines on bicuspid aortic valve with dilated ascending aorta.  Am J Cardiol. 2008;  102 (1) 107-110 (Epub 2008 Apr 22)
• 22 Ono M, Goerler H, Kallenbach K, Boethig D, Westhoff-Bleck M, Breymann T. Aortic valve-sparing reimplantation for dilatation of the ascending aorta and aortic regurgitation late after repair of congenital heart disease.  J Thorac Cardiovasc Surg. 2007;  133 (4) 876-879
• 23 Farhat F, Durand M, Boussel L, Sanchez I, Villard J, Jegaden O. Should a reimplantation valve sparing procedure be done systematically in type A aortic dissection?.  Eur J Cardiothorac Surg. 2007;  31 (1) 36-41 (Epub 2006 Oct 17)
• 24 Luciani G B, Mazzucco A. Aortic root disease after the Ross procedure.  Curr Opin Cardiol. 2006;  21 (6) 555-560
• 25 Aicher D, Langer F, Kissinger A, Lausberg H, Fries R, Schäfers H J. Valve-sparing aortic root replacement in bicuspid aortic valves: a reasonable option?.  J Thorac Cardiovasc Surg. 2004;  128 (5) 662-668
• 26 Lukács L, Haán A, Thomka I, Kassai I, Lengyel M. Valve repair in infective endocarditis.  Thorac Cardiovasc Surg. 1995;  43 (6) 326-330
• 27 Pethig K, Schäfers H J, Borst H G. Functional results after aortic valve repair in aortic root ectasia.  J Heart Valve Dis. 1996;  5 (3) 247-250
• 28 Alsoufi B, Borger M A, Armstrong S, Maganti M, David T E. Results of valve preservation and repair for bicuspid aortic valve insufficiency.  J Heart Valve Dis. 2005;  14 (6) 752-759
• 29 Leyh R G, Fischer S, Kallenbach K, Kofidis T, Pethig K, Harringer W, Haverich A. High failure rate after valve-sparing aortic root replacement using the “remodeling technique” in acute type A aortic dissection.  Circulation. 2002;  106 (12 Suppl. 1) I229-I233
• 30 Hess Jr P J, Harman P K, Klodell C T, Beaver T M, Bologna M T, Mikhail P, Tribble C G, Martin T D. Early outcomes using the Florida sleeve repair for correction of aortic insufficiency due to root aneurysms.  Ann Thorac Surg. 2009;  87 (4) 1161-1169
• 31 Kollar A C, Lick S D, Conti V R. Integrating resuspension with remodeling: early results with a new valve-sparing aortic root reconstruction technique.  J Heart Valve Dis. 2008;  17 (1) 74-80
• 32 Taylor W J, Thrower W B, Black H, Harken E D. The surgical correction of aortic insufficiency by circumclusion.  J Thorac Surg. 1958;  35 192-205
• 33 David T E, Armstrong S, Ivanov J, Webb G D. Aortic valve sparing operations: an update.  Ann Thorac Surg. 1999;  67 (6) 1840-1842
• 34 Anderson R H, Devine W A, Ho S Y, Smith A, McKay A. The myth of the aortic annulus: the anatomy of the subaortic outflow tract.  Ann Thorac Surg. 1991;  52 640-646
• 35 Grousson N, Lim K H, Lim H S, Ooi E T, Salgues S L, Yeo J H, Goetz W A. Ventriculo-aortic junction in human root. A geometric approach.  J Biomech. 2007;  40 (10) 2167-2173 (Epub 2006 Dec 12)
• 36 Choo S J, McRae G, Olomon J P, St George G, Davis W, Burleson-Bowles C L, Pang D, Luo H H, Vavra D, Cheung D T, Oury J H, Duran C M. Aortic root geometry: pattern of differences between leaflets and sinuses of Valsalva.  J Heart Valve Dis. 1999;  8 407-415
• 37 Sutton J P, Ho S Y, Anderson R H. The forgotten inner leaflet triangles: a review of the surgical anatomy of the aortic valve.  Ann Thorac Surg. 1995;  59 419-427
• 38 Brewer R J, Deck J D, Capati B, Nolan S P. The dynamic aortic root. Its role in aortic valve function.  J Thorac Cardiovasc Surg. 1976;  72 413-417
• 39 Dagum P, Green G R, Mistal F J, Daughters G T, Timek T A, Foppiano L E, Bolger A F, Ingels Jr M B, Miller D C. Deformation dynamics of the aortic root: modes and physiologic determinants.  Circulation. 1999;  100 (Suppl. II) II-54-II-62
• 40 Dahm M, Dohmen G, Groh E, Krummenauer F, Hafner G, Mayer E, Hake U, Oelert H. Decalcification of the aortic valve does not prevent early recalcification.  Heart Valve Dis. 2000;  9 (1) 21-26
• 41 Aubert S, Voiglio E, Chalabreysse L, Farhat F, Jegaden O. A new ultrasonic process for a renewal of aortic valve decalcification.  Cardiovasc Ultrasound. 2006;  4 2
• 42 Yacoub M H, Fagan A, Stassano P, Radley-Smith R. Results of valve conserving operations for aortic regurgitation (Abstract).  Circulation. 1983;  68 311-312
• 43 David T E. Aortic root aneurysms: remodeling or composite replacement?.  Ann Thorac Surg. 1997;  64 1564-1568
• 44 David T E, Ivanov J, Armstrong S, Feindel C M, Webb G D. Aortic valve-sparing operations in patients with aneurysms of the aortic root or ascending aorta.  Ann Thorac Surg. 2002;  74 (5) S1758-S1761
• 45 El Khoury G A, Underwood M J, Glineur D, Derouck D, Dion R A. Reconstruction of the ascending aorta and aortic root: experience in 45 consecutive patients.  Ann Thorac Surg. 2000;  70 1246-1250
• 46 Hopkins R A. Aortic valve leaflet sparing and salvage surgery: evolution of techniques for aortic root reconstruction.  Eur J Cardiothorac Surg. 2003;  24 886-897
• 47 Morishita K, Murakami G, Koshino T et al. Aortic root remodeling operation: how do we tailor a tube graft?.  Ann Thorac Surg. 2000;  73 1117-1121
• 48 Urbanski P P, Zhan X, Frank S, Diegeler A. Aortic root reconstruction using new vascular graft.  Interact Cardiovasc Thorac Surg. 2009;  8 (2) 187-190 (Epub 2008 Nov 21)
• 49 Matsumori M, Tanaka H, Kawanishi Y, Onishi T, Nakagiri K, Yamashita T, Okada K, Okita Y. Comparison of distensibility of the aortic root and cusp motion after aortic root replacement with two reimplantation techniques: Valsalva graft versus tube graft.  Interact Cardiovasc Thorac Surg. 2007;  6 (2) 177-181 (Epub 2007 Jan 26)
• 50 Settepani F, Szeto W Y, Pacini D, De Paulis R, Chiariello L, Di Bartolomeo R, Gallotti R, Bavaria J E. Reimplantation valve-sparing aortic root replacement in Marfan syndrome using the Valsalva conduit: an intercontinental multicenter study.  Ann Thorac Surg. 2007;  83 (2) S769-S773
• 51 van Son J A, Battellini R, Mierzwa M, Walther T, Autschbach R, Mohr F W. Aortic root reconstruction with preservation of native aortic valve and sinuses in aortic root dilatation with aortic regurgitation.  J Thorac Cardiovasc Surg. 1999;  117 1151-1156
• 52 David T E. Aortic valve sparing operations.  Ann Thorac Surg. 2002;  73 1029-1030
• 53 Demers P, Miller D C. Simple modification of “T. David-V” valve-sparing aortic root replacement to create graft pseudosinuses.  Ann Thorac Surg. 2004;  78 (4) 1479-1481
• 54 Cochran R P, Kunzelman K S, Eddy A C, Hofer B O, Verrier E D. Modified conduit preparation creates a pseudosinus in an aortic valve-sparing procedure for aneurysm of the ascending aorta.  J Thorac Cardiovasc Surg. 1995;  109 1049-1057
• 55 Thubrikar M J, Robicsek F, Gong G C, Fowler B L. A new aortic root prosthesis with compliant sinuses for valve-sparing operations.  Ann Thorac Surg. 2001;  71 S318-S322
• 56 De Paulis R, De Matteis G M, Nardi P, Scaffa R, Bassano C, Chiariello L. Analysis of valve motion after the reimplantation type of valve-sparing procedure (David I) with a new aortic root conduit.  Ann Thorac Surg. 2002;  74 53-57
• 57 Hioki M, Iedokoro Y, Kawamura J, Orii K, Masuda S, Tanaka S. Aneurysm of the left sinus of Valsalva causing aortic, mitral regurgitation and myocardial ischemia.  Jpn J Thorac Cardiovasc Surg. 2000;  48 476-479
• 58 Albes J M, Wahlers T. Valve-sparing root reduction plasty in aortic aneurysm: the “Jena” technique.  Ann Thorac Surg. 2003;  75 1031-1033
• 59 Casselman F P, Tan E S H, Vermeulen F E E, Kelder J C, Morshuis W J, Schepens M A A M. Durability of aortic valve preservation and root reconstruction in acute type A dissection.  Ann Thorac Surg. 2000;  70 1127-1133
• 60 Jeanmart H, de Kerchove L, Glineur D, Goffinet J M, Rougui I, Van Dyck M, Noirhomme P, El Khoury G. Aortic valve repair: the functional approach to leaflet prolapse and valve-sparing surgery.  Ann Thorac Surg. 2007;  83 (2) S746-S751
• 61 David T E, Armstrong S. Aortic cusp repair with Gore-Tex sutures during aortic valve-sparing operations.  J Thorac Cardiovasc Surg. DOI: 10.1016/j.jtcvs.2009.06.010 , Epub ahead of print 2009 Jul 16
  
• 62 Aicher D, Langer F, Adam O, Tscholl D, Lausberg H, Schäfers H J. Cusp repair in aortic valve reconstruction: does the technique affect stability?.  J Thorac Cardiovasc Surg. 2007;  134 (6) 1533-1538 (Epub 2007 Oct 26)
• 63 Hanke T, Charitos E I, Stierle U, Robinson D, Gorski A, Sievers H H, Misfeld M. Factors associated with the development of aortic valve regurgitation over time after two different techniques of valve-sparing aortic root surgery.  J Thorac Cardiovasc Surg. 2009;  137 (2) 314-319 (Epub 2008 Dec 19)
• 64 Patel N D, Weiss E S, Alejo D E, Nwakanma L U, Williams J A, Dietz H C, Spevak P J, Gott V L, Vricella L A, Cameron D E. Aortic root operations for Marfan syndrome: a comparison of the Bentall and valve-sparing procedures.  Ann Thorac Surg. 2008;  85 (6) 2003-2011
• 65 Sareyyupoglu B, Suri R M, Schaff H V, Dearani J A, Daly R C, Orszulak T A, Sundt T M. Survival and reoperation risk following bicuspid aortic valve-sparing root replacement.  J Heart Valve Dis. 2009;  18 (1) 1-8
• 66 Gariboldi V, Grisoli D, Kerbaul F, Giorgi R, Riberi A, Metras D, Mesana T G, Collart F. Long-term outcomes after repaired acute type A aortic dissections.  Interact Cardiovasc Thorac Surg. 2007;  6 (1) 47-51 (Epub 2006 Oct 9)
• 67 Frater R W. Aortic valve insufficiency due to aortic dilatation: correction by sinus rim adjustment.  Circulation. 1986;  74 I136-I142
• 68 Khaladj N, Ismail I, Shrestha M, Peterss S, Pichlmaier M, Kallenbach K, Haverich A, Hagl C. Aortic root surgery in combination with hypothermic circulatory arrest: preserve or replace the aortic valve in the context of postoperative neurological outcome? A case match comparison.  Interact Cardiovasc Thorac Surg. 2009;  9 246-250
• 69 Nötzold A, Gerriets T, Eggers J, Kupiske G, Seidel G, Kaps M, Sievers H H. Circulating microemboli after composite replacement or valve-sparing aortic root surgery.  Thorac Cardiovasc Surg. 2002;  50 (3) 141-144
• 70 Kallenbach K, Karck M, Pak D, Salcher R, Khaladj N, Leyh R, Hagl C, Haverich A. Decade of aortic valve sparing reimplantation: are we pushing the limits too far?.  Circulation. 2005;  112 (Suppl. 9) I253-I259
• 71 Maselli D, Minzioni G. A technique to reposition sinotubular junction in aortic valve reimplantation procedures with the De Paulis Valsalva graft.  Eur J Cardiothorac Surg. 2006;  29 (1) 107-109 (Epub 2005 Dec 6)
• 72 Lansac E, Di Centa I, Bonnet N, Leprince P, Rama A, Acar C, Pavie A, Gandjbakhch I. Aortic prosthetic ring annuloplasty: a useful adjunct to a standardized aortic valve-sparing procedure?.  Eur J Cardiothorac Surg. 2006;  29 (4) 537-544 (Epub 2006 Feb 24)
• 73 Takayama H, Smith C R, Bowdish M E, Stewart A S. Open distal anastomosis in aortic root replacement using axillary cannulation and moderate hypothermia.  J Thorac Cardiovasc Surg. 2009;  137 (6) 1450-1453 (Epub 2009 Feb 28)
• 74 Milano A D, Pratali S, Mecozzi G, Boraschi P, Braccini G, Magagnini E, Bortolotti U. Fate of coronary ostial anastomoses after the modified Bentall procedure.  Ann Thorac Surg. 2003;  75 (6) 1797-1802
• 75 Kasimir M T, Simon P, Seebacher G, Deviatko E, Simon-Kupilik N, Moritz A, Wolner E, Moidl R. Reconstructed bicuspid aortic valve after 10 years: clinical and echocardiographic follow-up.  Heart Surg Forum. 2004;  7 (5) E485-E489
• 76 von Oppell U O, Karani Z, Brooks A, Brink J. Dissected aortic sinuses repaired with gelatin-resorcin-formaldehyde (GRF) glue are not stable on follow up.  J Heart Valve Dis. 2002;  11 249-257
• 77 Lansac E, Lim H S, Shomura Y, Lim K H, Rice N T, Goetz W, Acar C, Duran C M G. A four-dimensional study of the aortic root dynamics.  Eur J Cardiothoracic Surg. 2002;  22 497-503