It's Topic Tuesday!- Aortic Root Surgery

Happy Tuesday, everyone! With aortic root disease, patients and surgeons have several options for aortic root replacement. Today, we’ll be discussing these different techniques and the advantages and disadvantages of each. 

What is special about the Aortic Root?

The aortic root is the section of the aorta closest to the heart, where the aortic valve sits. Unlike the ascending aorta, replacement of this section of the aorta requires management of the coronary arteries, which branch off of the root and must be reconnected after the aorta is replaced. Because the aortic valve is closely related to the root, it must also be managed. In general, operations are separated into Composite Valve Graft Root Replacements and Valve Sparing Root Replacements.

Compositive Valve Graft Root Replacement, also called the Bentall or the Bentall-de Bono Procedure, involves replacing the aortic root as well as the valve

https://www.cardiosurgeon.co.uk/treatment-guide/aortic-root/

For this procedure, the aortic valve annulus (or ring in which the aortic valve sits) is sized and a graft is selected with a valve that fits accordingly. Commonly, the fabric aortic graft and aortic valve prosthesis are prefabricated into a single unit that can be directly implanted. Patients may receive either a mechanical valve (which may last forever but requires lifelong anticoagulation) or a biologic valve (which does not require long-term anticoagulation but does degrade over time).

The Valve Sparing Root Replacement usually encompasses 2 techniques: the “Yacoub Procedure” (or root remodeling) and the “David Procedure” (or root reimplantation). Both of these techniques involves preserving the patient’s own aortic valve, which has the advantage of lasting longer than a biologic valve replacement without requiring the anticoagulation that would otherwise be needed for a mechanical valve. The Yacoub procedure involves cutting out the aortic root sinuses (where the aorta “outpouches” and sewing a graft to the valve to the graft in a crown-shaped manner.

https://journals.sagepub.com/doi/10.1177/1089253213513842

The David procedure involves sewing a graft around the base of the aortic root (below the aortic valve annulus) and then sewing the valve itself in a 3-dimensional configuration inside the graft to ensure a water tight seal and functioning valve. The additional suture line at the base of the root has the benefit of reinforcing the aortic valve annulus and preventing it from stretching over time.

https://link.springer.com/chapter/10.1007/978-3-7091-4874-7_51

For both of these procedures, the coronary arteries are then reimplanted as “buttons” to allow blood to flow from the aorta to the heart muscle. Then, the new fabric root is reconnected to the patient’s native aorta and the procedure is complete.

How Do Surgeons Choose Between Them?

Both surgeries have excellent outcomes, the choice depends on the patient and the valve itself. Some factors your surgical team will consider include:

1. Condition of your aortic valve

If the valve is healthy or can be repaired, a valve-sparing operation may be an option.

2. Age and lifestyle

Younger patients often benefit from mechanical valves over biologic valves to reduce the need for reoperation.

3. Surgeon experience

Not all surgeons perform valve-sparing operations regularly. A Bentall may be recommended if a valve-sparing operation is not suitable or if a surgeon believes it will provide a more predictable long-term result.

That’s all for today, thanks again for tuning in to another Topic Tuesday!

-Purab