[Preservation of the native aortic valve in the treatment of aortic aneurysmal dilatation]

Abstract

Mechanical valve conduit replacement of the aortic root is a durable and appropriate procedure for aortic root dilatation with or without aortic aortic insufficiency. But this procedure may sacrifice an anatomically salvageable aortic valve and requires a life-long anticoagulation with its attendant thromboembolic versus haemorrhagic risks, which is not ideal for young active patients. Recently, two techniques of aortic root replacement with aortic valve sparing have been described, based on experimental data. The first one is Yacoub's procedure (1983), where the correction of the aortic root is performed by correcting the sinotubular junction and replacement of the aortic sinuses with an appropriately tailored Dacron graft (remodelling). The second technique was described by David (1992). In this one, the aortic root reconstruction is performed by reimplanting the aortic valve in a tubular Dacron graft (reimplantation). Since 1993, we have been interested in these procedures and the aim of this study was to examine the perioperative and intermediate term results of these techniques. From 1993 to 1998, 14 patients had either reimplantation of the aortic valve (3 patients) or remodelling of the aortic root (11 patients). Patients' ages ranged from 17 to 57 years (40.2 +/- 7.9 years). Four patients had Marfan's syndrome (29%). There were 11 cases of aortic insufficiency, three 1+ (21.4%), 3+ (21.4%), seven 2+ (50%) and one 3+ (7.2%). All the patients had morphologically normal aortic leaflets. The mean diameter of the sinuses was 57 +/- 4 mm. There was no acute or chronic dissection. The left ventricular function was measured as the percentage of the fractional shortening of the left ventricular diameter. The mean of the fractional shortening was 38.3 +/- 4%. There was no mortality and all patients underwent early and late follow-up echocardiography. The 14 patients have only mild or no insufficiency, which has not progressed in any patient. No other valve-related complication has occurred. Aortic valve-sparing replacement of the aortic root is an excellent procedure for patients with aortic root dilatation and anatomically salvageable valves. The long-term results are still unknown but it seems an attractive alternative to composite replacement of the aortic valve and descending aorta. Morbidity and mortality rates are very low, even lower than a Bentall procedure, while the savings in cost and human lives due to the absence of a mechanical valve prosthesis are significant.