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Physician Insight:
Advice to potential aortic valve disease patients

Cardiac: Join Dr. Girardi and Dr. Isom, surgeons at NewYork-Presbyterian Hospital/Weill Cornell Medical Center, as they present a valve-sparing procedure. Live 8:00 PM (00:00 13/06/07 UTC)

Patients with aneurysms of the aortic root often have dilatation of the aorta down to the aortic valve annulus. Successful reconstruction of this delicate area must first entail complete resection of all abnormal aortic tissue down to, and sometimes including, the aortic valve. The gold standard operation for patients with these types of aneurysms has been composite replacement of the aortic root with a one-piece component consisting of a dacron aortic graft and an aortic valve replacement, either a mechanical or biologically valve. This procedure can be performed with exceptionally low morbidity and mortality; however, patients were subjected either to lifelong anticoagulation when choosing a mechanical valve or the potential need for reoperation when their biological valves failed.

Valve-sparing aortic root reconstruction was first introduced in the early 1980s by Yacoub in England in a procedure called aortic root remodeling. In this procedure, all aortic tissue was removed down to the aortic annulus, the aortic valve was saved and the sinuses of Valsalva were reconstructed around the valve with a scalloped dacron graft. This allowed the patient to be free of the risk of aneurysm rupture while retaining native valve function, free of the need for anticoagulation. The durability of this procedure, however, came into question as it failed to address the potential for continued aortic root dilatation. Some patients undergoing this type of valve-sparing reconstruction presented with significant aortic valve regurgitation and subsequently required reoperation and aortic valve replacement.

A second type of valve-sparing aortic root reconstruction was subsequently developed by David in Toronto. This technique, reimplantation, also excised the entire diseased aortic root while retaining the patients' native aortic valve. However, unlike the remodeling technique, the aorta is not reconstructed around the valve. Rather, the valve is reimplanted inside a dacron graft that is anchored to the aortic root below the valve. This stabilizes the aortic annulus, preventing further aortic dilatation, thus eliminating the need for aortic valve replacement because of central aortic insufficiency. The durability of native valve function is enhanced and good short-term and intermediate-term results have been produced. Reimplantation is currently the most common form of valve-sparing aortic root reconstruction practiced by surgeons with expertise in this area.

In this session, a patient with an aortic root aneurysm and excellent native aortic valve function will undergo a valve-sparing aortic root replacement utilizing the original reimplantation technique, the so called David I procedure.



Leonard Girardi

Leonard Girardi, MD

O. Wayne Isom Professor of Cardiothoracic Surgery, Weill Cornell Medical College, Director, Aortic Surgery Program, Attending Cardiothoracic Surgeon, NewYork-Presbyterian/Weill Cornell

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