Aortic Root Surgery in Adults: An Unsolved Problem

Abstract

Nowadays, despite the rapid advancements in interventional cardiology, open surgery still deals with aortic root diseases, to assure the best "ad hoc" treatment. In case of middle-aged adult patients, the optimal operation still represents a matter of debate. A review of the last 10-year literature was conducted, focusing on patients below 65 to 70 years of age. Because of the small sample and the heterogeneity of the papers, no metanalysis was possible. Bentall-de Bono procedure, valve sparing, and Ross operations are the surgical options currently available. The main issues in the Bentall - de Bono operation are lifelong anticoagulation therapy and cavitation in case of mechanical prosthesis implantation and structural valve degeneration in case of biological Bentall. As transcatheter procedures are currently performed as valve in valve, biological prosthesis may be preferable, if the diameter may prevent postoperative high gradients. Conservative techniques, such as remodeling and reimplantation, preferred in the young, guarantee physiologic aortic root dynamics and impose surgical analysis of the aortic root structures to get a durable result. The Ross operation, which shows excellent performance, involves autologous pulmonary valve implantation and is performed only in experienced and high-volume centers. Due to its technical difficulty, it requires a steep learning curve and presents some limitations in specific aortic valve diseases. All three have advantages and downsides, and no ideal solution has still been reported.

Fig. 1

Bentall–de Bono operation: valved straight graft replacing the aortic root. Both biological and mechanical prosthesis can be used, even if our drawings does not show the valve.

Fig. 2

Remodeling operation: three “petals” of a bulged vascular graft sutured to the native aortic valve and ring annuloplasty.

Fig. 3

Reimplantation operation: native aortic valve sutured inside a straight vascular graft.

Fig. 4

The Ross operation: pulmonary autograft in aortic position and pulmonary homograft.