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Ann Thorac Surg 2002;73:724
© 2002 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, The Bowman Gray School of Medicine, Wake Forest University, 300 South Hawthorne Rd Winston-Salem, NC 27157-1096, USA
e-mail: nkon{at}wfubmc.edu
This article addresses the common finding when doing aortic valve surgery: an ascending aorta which is dilated, and the question that comes to the surgeon’s mind is whether or not to replace the aorta. There is the worry that progressive dilation of the ascending aorta will lead to further problems for the patient, specifically aneurysmal formation or aortic dissection at a later date. This article describes two techniques to handle a dilated ascending aorta at time of aortic valve replacement for bicuspid aortic valve disease. First, one can simply take a segment out of the existing aorta and re-close it, thereby reducing the size of the aorta. The second method of handling the dilated aorta in this paper involves external wrapping of the aorta after reducing the size of the native aorta. Both of these techniques have been in practice for some time. Both of these techniques are believed to be effective.
The concept of reducing the size of the ascending aorta becomes particularly important when one is implanting a stentless valve, whether it be a pulmonary autograft, an aortic allograft or a stentless porcine valve. Both Dr Elkins [1] (when performing a pulmonary autograft) and Dr David [2] (when performing a subcoronary stentless valve implantation) have demonstrated progressive aortic insufficiency when there is a mismatch in the size of the ascending aorta above the sinotubular junction. If the size of the sinotubular junction is maintained, the autograft, allograft or stentless porcine valve is more likely to maintain normal geometry and thus valvular competence.
My own personal belief is that a reduction tailoring aortoplasty, whether one wraps it or not, is a less reliable, more difficult, cumbersome, and complicated procedure than simply replacing the ascending aorta with an appropriate sized Dacron graft. Replacement of the ascending aorta with a Dacron graft is greatly simplified by using a brief period of hypothermia and circulatory arrest. Dacron graft replacement requires two circular suture lines which are under less tension and stress than an anterior or lateral aortoplasty suture line. This concept is well known from data and experience performing aortoplasty for coarctation of the aorta. Both techniques of reduction aortoplasty in this article proved to be effective and certainly can be used if the surgeon feels comfortable with the techniques. I would again stress the importance of performing aortic replacement or reduction aortoplasty when using stentless aortic valve prostheses to replace the aortic valve [1, 2].
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