Introduction:
Bentall and De Bono described aortic root replacement with a composite
valve conduit in their seminal paper in 1968(1). The
Bentall procedure underwent several modifications over the following
decades and remained the standard of care for addressing aortic root
aneurysms(2, 3). However, it was realized that there
was a subset of patients with aortic root pathology confined only to the
aortic sinuses with normal aortic cusp anatomy and valve function; in
this cohort of patients it is conceivable that addressing the aortic
wall pathology while preserving the native valve function would be
advantageous. Based on this observation Sir Magdi introduced the
remodelling procedure, replacing the sinuses of valsava while preserving
the valve leaflets(4). Subsequently, the
reimplantation procedure was developed to address the limitation of the
remodelling technique in stabilising the aortic
annulus(5, 6).
In Type A aortic dissection, the aortic valve cusps are often normal
which makes the application valve conserving techniques to patients with
Type A Acute Aortic Dissection very appealing (TAAAD)(7). The enthusiasm for valve sparing root replacement
(VSRR) is driven by reoperation rates following supracomissural aortic
replacement in TAAAD being as high as 44% in young patients;
conversely, in the same cohort of patients who had root aortic root
replacement the freedom from root reintervention was 100% at 7 years;
furthermore, replacement of the aortic valve with prosthesis is
associated with risks related to anticoagulation for mechanical valves
and structural valve degeneration of bioprostheses(8,
9).
In this paper we discuss -in patients with TAAAD- when should the root
be replaced, selecting the right patients for VSRR, techniques of VSRR,
lessons learnt from our experience at Emory, and outcomes of VSRR in
patients with TAAAD.