Commentary: Valve sparing in aortic root aneurysms—An old promise or a concrete chance?

Abstract

The restoration of the normal dimension and geometry of aortic root, in particular in patients with genetic collagen disorders, improves survival and reduce incidence of adverse aorta-related events. 1 For many years, the standard treatment for patients with aortic root aneurysm consisted in aortic root replacement with composite mechanical valve conduit and coronary reimplantation. 2 Inspired by the mitral experience, reconstructive methods of sparing the aortic valve, associated with replacement of the other component of the aortic root, have been developed with the aim of reducing the risk of thromboembolic and endocarditis events while restoring the normal life expectancy and quality of the life. 3 In this issue of the Journal, Kunihara and colleagues 4 report Japanese Cardiovascular Database outcomes of more than 5000 patients undergoing aortic root replacement with valve-sparing root replacement (VSRR) techniques or composite graft-valve (CGV) procedures with mechanical or biological prostheses. Even though VSRR procedures (remodeling and reimplantation techniques) had longer cardiopulmonary bypass and crossclamp times, Kunihara and colleagues 4 concluded that aortic valve-sparing root replacement was associated with lower morbidity and mortality than CGV. Specifically, the CGV group had a significantly higher incidence of postoperative stroke and prolonged ventilation (>72 hours). Finally, in-hospital mortality was significantly higher in the CGV group than in the VSRR group. 4 This article by Kunihara and colleagues 4 offers an important contribution regarding the dilemma of whether replacing the aortic valve is better than sparing it when aortic root replacement is required. With a large sample size, after matching, Kunihara and colleagues 4 confirm data that VSRR can reduce valve-related complications. Avoiding lifelong oral anticoagulation, valve-sparing procedures reduce the hemorrhagic or thromboembolic adverse events seen with mechanical CGV. Moreover, VRSS may reduce valve dysfunction and reoperation rate relative to bioprostheses. 4 The intuitive message that preservation of the native valve is better than replacement has been consistently supported by David and colleagues. 5 As Kunihara and colleagues 4 state, in most cases, aortic valve cusps are normal or stretched from annuloaortoectasia, and the valve can recover its normal function once normal root geometry has been restored.Concerns remain about valve-sparing surgery, however, with regard to indications, reproducibility, success rate, and duration. Since David and Yacoub developed the reimplantation and remodeling techniques, 6,7 VSRR procedures gained great popularity but never reached a widespread diffusion, with operations on the aortic root not exceeding 15% of surgical procedures. 8 These strategies actually remain technically demanding and require a deep knowledge of aortic root and valve geometry, anatomy, and dynamics. 9 Unsatisfactory VSRR could lead to an early failure. The most common pitfalls are represented by incorrect graft s...