Progress in surgical interventions for aortic root aneurysms and dissections

ABSTRACT

Introduction

The aortic root is a uniquely sensitive region as it anatomically encompasses the aortic valve leaflets and gives origin to the coronary arteries. These associated structures, in addition to the aortic tube, itself, add immensely to the complexity of replacing this segment when it is aneurysmal or dissected. Given this complexity, many contemporary choices for treatment of aortic root aneurysms have evolved over the past few decades.

Areas covered

The aim of this study was to provide an updated review of the literature regarding various surgical options for management of aortic root aneurysmal disease. A systematic search in PubMed database was performed for articles related to various aortic root surgeries and outcomes published between 1998 and 2020.

Expert opinion

For multiple technical options in aortic root replacement surgery, decades of surgical investigation and development have shown favorable results, which provide a formidable armamentarium to be used at the discretion of the surgeon to suit various patient anatomic patterns and risk profiles – while still durably controlling the aortic pathology and protecting from recurrence, valve dysfunction, progressive dilatation, and aortic dissection.

KEYWORDS:

• Aneurysm
• aortic root
• Bentall procedure
• David procedure. valve-sparing procedure
• PEARS procedure
• Florida sleeve

Article highlights

• As more patients present for aortic root surgery at an advanced age or with multiple co-morbidities, placing them at increased surgical risk, it is imperative for today’s cardiac surgeon’s armamentarium to include an array of techniques to suit various patient risk profiles.

• Those who are young with low surgical risk, who have a diseased valve with bicuspid morphology, whose root dilation is greater than 4 cm, or who have a connective tissue disorder can undergo an aortic root replacement with a mechanical valved conduit or a valve-sparing aortic root replacement

• Options for acute aortic dissection are multiple and have been widely discussed in the literature: root-sparing resection, full root resection, and root reimplantation can all be considered in suitable patients.

• Root sparing surgery or the Florida (FL) Sleeve technique may be used in high-risk surgical patients to avoid post-operative ischemic complications, in case of surgeons not being comfortable with the technical complexities of full root replacement surgery.

• Single sinus replacement or V-shaped non-coronary sinus resections are used very selectively, usually in elderly patients or those requiring concomitant extensive non-aortic cardiac surgical procedures.

• The PEARS technique is just entering the mainstream of options and enables preservation of the aortic valve, while providing a definitive means to hold the sinuses and ascending aorta at a stable size and shape.

Declaration of interest

J Elefteriades reports that they are a Principal of CoolSpine, on the data/safety monitoring board of Terumo, and consultant for CryoLife.

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.