2008 William W. L. Glenn Lecture—Aortic Valve Sparing: Matching the Procedure to the Aortic Root Pathology
Aortic valve-sparing operations are complex procedures because they require exceptional knowledge of the functional anatomy and pathology of the aortic valve as well as technical expertise.
There are basically two types of aortic valve-sparing operations to treat aortic root aneurysm: remodeling of the aortic root and reimplantation of the aortic valve. Remodeling of the aortic root is a physiologically sounder procedure than reimplantation of the aortic valve because it preserves annular motion, but we have shown that the aortic annulus of young patients with aortic root aneurysms may dilate after surgery, and aortic insufficiency eventually ensues. On the other hand, older patients with ascending aortic aneurysm and dilated sinotubular junction and aortic sinuses but with normal aortic annulus and relatively normal cusps do very well with remodeling of the aortic root.
From 1988 to June 2008, we performed 447 aortic valve-sparing operations at Toronto General Hospital: 312 for aortic root aneurysms and 135 for ascending aortic aneurysm with dilation of the sinotubular junction or one or more aortic sinuses. One third of the patients with aortic root aneurysm had the stigmata of Marfan syndrome, and 10% had bicuspid aortic valve. The overall operative mortality was 1%, and the 10-year survival was identical to that of the general population matched for age and gender. The 10-year freedom from moderate and severe aortic insufficiency was 95% at 10 years.
Our experience supports the continued use of these operations to preserve the native aortic valve, including in young adults with or without the Marfan syndrome, as long as the aortic cusps are normal or minimally stretched.