Valve-sparing aortic root replacement in patients with the Marfan syndrome

See related article on page 789. Y our Editor solicited commentary for this provocative article,1 not so much to enter the fray concerning which method of valvesparing aortic root replacement—Yacoub remodeling versus David reimplantation—is best for patients with the Marfan syndrome (MFS), but to clarify for the readership the key differences between the two procedures and how these operations have evolved. I will also emphasize six points raised by the article. Historically, conventional cardiovascular surgical treatment for patients with the MFS who have aneurysm or dissection involving the ascending aorta has been replacement of the entire aortic root and valve with a composite valve graft (CVG) and reimplantation of the coronary artery ostia. A CVG incorporating a mechanical valve is usually used because most of these patients are young, can safely tolerate anticoagulation with warfarin, and do not wish to accept the risk of another operation. Over the past 30 years, CVG has become a low risk operation and a very durable one for patients with the MFS.2-4 On the other hand, some patients have medical contraindications that make indefinite anticoagulation inadvisable, others are not medically compliant enough for anticoagulation to be safe, some individuals have lifestyles that make anticoagulation hazardous, others do not have secure long-term access to health insurance or continuing medical care, some have an aversion to anticoagulation, and the older patients do not need a new valve that will last for many decades. In these relatively infrequent circumstances, the aortic root and valve can be replaced with an allograft aortic root, a stentless porcine xenograft aortic root, or a Dacron tube graft with a stented bioprosthesis sewn into it.4 A Ross-Shumway procedure is contraindicated because of the aneurysmal disease and underlying connective tissue disorder. The durability of all these various tissue valve alternatives, however, is limited. Furthermore, the risk at reoperation is not negligible; for example, an allograft may be densely calcified, sternal re-entry may be perilous, the coronary ostia need to be reimplanted again, and the aortic annulus may have scarred down excessively. Another option gaining popularity for those wishing to avoid anticoagulation is valve-sparing aortic root replacement. But this option is also a trade-off. How many years without warfarin will the valve last before a second operation becomes necessary? Valve-sparing aortic root replacement operations can be subdivided into two general families: (1) the Yacoub “remodeling” procedure used since 19795-9 and (2) the David “reimplantation” procedure performed since 1988.1,10-14 The paper under discussion in this issue1 of the Journal is focused solely on 105 patients with the MFS classified strictly according to the Ghent criteria: 44 patients received a CVG and 61 underwent valve-sparing aortic root replacement. What is the difference between the remodeling and the reimplantation methods of valve-sparing aortic root replacement? The easiest way to distinguish between them is whether the procedure From the Department of Cardiovascular Surgery, Stanford University School of Medicine, Stanford, Calif.