Portal de Periódicos da CAPES

Valve-Sparing Aortic Root Replacement: Current State of the Art and Where Are We Headed?

2007; Elsevier BV; Volume: 83; Issue: 2 Linguagem: Inglês

10.1016/j.athoracsur.2006.10.101

1552-6259

D. Craig Miller,

Infective Endocarditis Diagnosis and Management

Doctor Miller discloses that he has financial relationships with Medtronic Heart Valve Division, Inc., Edwards Lifesciences, LLP, Boston Scientific Corp., 3F Corporation, and St. Jude Medical, IncSince Sir Magdi Yacoub pioneered aortic root “remodeling” in 1979 [1Yacoub M. Fagan A. Stassano P. Radley-Smith R. Results of valve conserving operations for aortic regurgitation.Circulation. 1983; 68 ([Abstract]): 321PubMed Google Scholar, 2Sarsam M.A.I. Yacoub M. Remodeling of the aortic valve annulus.J Thorac Cardiovasc Surg. 1993; 105: 435-438PubMed Google Scholar] and Tirone David [3David T.E. Feindel C.M. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta.J Thorac Cardiovasc Surg. 1992; 103: 617-621PubMed Google Scholar] followed in 1988 with the “reimplantation” method to preserve the patient’s native aortic valve when replacing an aortic root aneurysm with a graft, both procedures have been demonstrated to be applicable to many patients with aortic root pathology and aortic regurgitation (AR), including those with the Marfan syndrome (MFS) [4Miller D.C. Valve-sparing aortic root replacement in patients with the Marfan syndrome.J Thorac Cardiovasc Surg. 2003; 125: 773-778Abstract Full Text Full Text PDF PubMed Scopus (188) Google Scholar]. The hope has been that cumulative valve-related morbidity and mortality would be lower after a valve-sparing operation compared with after composite valve grafting utilizing a mechanical prosthesis and indefinite warfarin anticoagulation, which represents the surgical “gold standard.” While preserving the native aortic valve liberates the patient from the need for life-long anticoagulation, the unanswered question has been valve durability after a Yacoub or David procedure. The popularity of valve-sparing aortic root replacement has escalated rapidly recently owing in no small part to patient demand, but the key question remains [4Miller D.C. Valve-sparing aortic root replacement in patients with the Marfan syndrome.J Thorac Cardiovasc Surg. 2003; 125: 773-778Abstract Full Text Full Text PDF PubMed Scopus (188) Google Scholar]: How many years without warfarin will the valve last before a second operation might become necessary? This also is the rationale for the ongoing international registry in 22 North American and European centers sponsored by the National Marfans Foundation comparing composite valve grafting with various types of valve-sparing aortic root replacement procedures in MFS patients. In the interim, what do we know with any modicum of certainty? Based on currently available knowledge, valve durability unfortunately has not been universally satisfactory, prompting some well-known centers to argue that valve-sparing aortic root replacement should be abandoned or limited just to those patients who cannot safely receive anticoagulation therapy [5Zehr K.J. Matloobi A. Connolly H.M. Orszulak T.A. Puga F.J. Schaff H.V. Surgical management of the aortic root in patients with Marfan syndrome.J Heart Valve Dis. 2005; 14: 121-129PubMed Google Scholar, 6Zehr K.J. Orszulak T.A. Mullany C.J. et al.Surgery for aneurysms of the aortic root—a 30-year experience.Circulation. 2004; 110: 1364-1371Crossref PubMed Scopus (160) Google Scholar]. Further, the mortality rate for valve-sparing aortic root replacement has been excessive in other centers [7Hess Jr, P.J. Klodell C.T. Beaver T.M. Martin T.D. The Florida sleeve: a new technique for aortic root remodeling with preservation of the aortic valve and sinuses.Ann Thorac Surg. 2005; 80: 748-750Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar]. These problems are related in part to surgeon inexperience in aortic root surgery, surgeon unfamiliarity with the pathological anatomy, lack of conceptual understanding of the procedure by surgeons (eg, unnecessarily using pledgeted sutures inside the left ventricular outflow tract tied firmly to the graft), and false surgical pride.First, the 15- to 20-year results after composite valve grafting in patients with MFS were shown by Gott and colleagues [8Gott V.L. Greene P.S. Alejo D.E. et al.Replacement of the aortic root in patients with Marfan’s syndrome.N Engl J Med. 1999; 340: 1307-1313Crossref PubMed Scopus (501) Google Scholar] to be outstanding if operation was performed electively before acute aortic dissection or aortic rupture. Morbidity attributed to anticoagulant-related complications was rare, and the thromboembolic and prosthetic valve endocarditis rates were low. Thus, the clinical performance bar has been set very high: the incidence of valve-related morbidity and mortality after valve-sparing aortic root replacement must equal or exceed these standards [4Miller D.C. Valve-sparing aortic root replacement in patients with the Marfan syndrome.J Thorac Cardiovasc Surg. 2003; 125: 773-778Abstract Full Text Full Text PDF PubMed Scopus (188) Google Scholar]. Either type of valve-sparing aortic root replacement is safe, fairly reproducible, and associated with reasonable results in selected patients, at least in the hands of certain surgeons. The surgical learning curve, however, is very steep and unforgiving. If the aortic valve cusps are not pathologically damaged, the vast majority of these valves can be conserved; relative contraindications in the past (eg, very large aortic annulus, severe AR or eccentric AR jet due to cusp prolapse, or both, and so forth) have been overcome with new surgical techniques.The outcomes at 10 years and beyond notwithstanding excellent survival statistics, however, are not ideal. Even in the best surgical centers, 25% to 30% of MFS patients undergoing valve-sparing aortic root replacement have 3+/4+ recurrent AR at 10 years, and small numbers have required aortic valve replacement (AVR) [9de Oliveira N.C. David T.E. Ivanov J. et al.Results of surgery for aortic root aneurysm in patients with the Marfan syndrome.J Thorac Cardiovasc Surg. 2003; 125: 789-796Abstract Full Text Full Text PDF PubMed Scopus (204) Google Scholar]. The long-term durability data are still scanty and follow-up is limited, but most surgical authorities today use the David reimplantation method (including creation of Dacron pseudosinuses) since one can adjust annulus size to whatever is ideal for that individual patient and the annulus cannot dilate postoperatively [4Miller D.C. Valve-sparing aortic root replacement in patients with the Marfan syndrome.J Thorac Cardiovasc Surg. 2003; 125: 773-778Abstract Full Text Full Text PDF PubMed Scopus (188) Google Scholar]. The incidence of postoperative bleeding is higher after a Yacoub procedure [9de Oliveira N.C. David T.E. Ivanov J. et al.Results of surgery for aortic root aneurysm in patients with the Marfan syndrome.J Thorac Cardiovasc Surg. 2003; 125: 789-796Abstract Full Text Full Text PDF PubMed Scopus (204) Google Scholar]. Professor Sir Magdi Yacoub’s personal results in 82 MFS patients showed that 17% required reoperation by 10 years, and an additional 22% had moderate AR at the time of last follow-up (mean, 5.5 years; median, 3) [10Birks E.J. Webb C. Child A. Radley-Smith R. Yacoub M.H. Early and long-term results of a valve-sparing operation for Marfan syndrome.Circulation. 1999; 100: 29-35Google Scholar]. Discouraging results at Johns Hopkins in children and young adults after Yacoub procedures prompted Cameron to switch to the David technique in 2002 [11Cattaneo S.M. Bethea B.T. Alejo D.E. et al.Surgery for aortic root aneurysm in children: a 21-year experience in 50 patients.Ann Thorac Surg. 2004; 77: 168-176Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar]. The Hannover (Germany) 1993 to 2005 experience (exclusively T. David-I reimplantation using a cylindrical graft) totals 325 patients, 59 of whom had MFS [12Kallenbach K. Karck M. Pak D. et al.Decade of aortic valve sparing reimplantation: are we pushing the limits too far?.Circulation. 2005; 112: 253-259Google Scholar]. Freedom from AVR was 80% ± 9% at 10 years, but MFS was a risk factor for late AVR. David’s most recent updated experience in 220 patients (40% with MFS; mean age, 46 years; average follow-up, 5.2 ± 4 years) revealed an operative mortality of 1% (3 of 220) and overall freedom estimate from 3+ or 4+ AR of 85% ± 5% at 10 years (94% ± 4% after David reimplantation versus 75% ± 10% after Yacoub remodeling, p = 0.04) [13David T.E. Feindel C.M. Webb G.D. Colman J.M. Armstrong S. Maganti M. Long term results of aortic valve sparing operations for aortic root aneurysm.J Thorac Cardiovasc Surg. 2006; 132: 347-354Abstract Full Text Full Text PDF PubMed Scopus (232) Google Scholar]. Late AVR was necessary in 5 patients (freedom from AVR at 10 years was 95% ± 3%). David and colleagues [13David T.E. Feindel C.M. Webb G.D. Colman J.M. Armstrong S. Maganti M. Long term results of aortic valve sparing operations for aortic root aneurysm.J Thorac Cardiovasc Surg. 2006; 132: 347-354Abstract Full Text Full Text PDF PubMed Scopus (232) Google Scholar] concluded that the reimplantation method proffers better durability; however, it should be noted that multivariable analysis using propensity score matching or case control statistical techniques were not employed to test this hypothesis rigorously, as the Yacoub and David patient cohorts differed.The basis for my opinion and prejudices rests on our 13-year experience at Stanford, where we have performed 134 valve-sparing aortic root replacement procedures between July 1993 and April 2006. Seventy-two patients had MFS. There were a total of 120 T. David reimplantations and 14 Yacoub remodeling procedures (Fig 1). We started with the T. David-I operation and then tried the Yacoub technique in the late 1990s; even though the remodeling approach is quicker and saves one suture line, one reoperation due to annular dilatation and recurrent AR prompted abandoning the Yacoub approach after 12 adult cases. We then reverted to the T. David-IV technique, and in May 2001 (the same month Dr David independently but similarly began using a larger graft necked down both proximally at the annulus and distally at the sinotubular junction) adopted the T. David-V method.In December 2002, we developed our simplified T. David-V technique (“Stanford modification”) using one large graft and one small graft, which creates large, billowing Dacron pseudosinuses [14Demers P. Miller D.C. Simple modification of “T. David-V” valve-sparing aortic root replacement to create graft pseudosinuses.Ann Thorac Surg. 2004; 78: 1479-1481Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar]. Twenty-five cases were performed in 2005 and 12 in the first 4 months of this year, which extrapolates to a total of 30 to 40 cases in 2006. I continue to prefer fabricating a custom-designed “sinus prosthesis” using two grafts because every important dimension (ie, new annular diameter, sinus diameter, sinus and commissure height, and sinotubular junction diameter) can be individualized for each patient; the commercially available sinus graft developed by De Paulis does not provide this unlimited degree of flexibility. The difference in sizes between the large and small grafts has varied from 8 to 12 mm, with the large graft diameter ranging from 30 to 36 mm (one was 38 mm).On the other hand, one can oversize the proximal graft excessively; I do not concur with Aybek and colleagues [15Aybek T. Sotiriou M. Wöhleke T. et al.Valve opening and closing dynamics after different aortic valve-sparing operations.J Heart Valve Dis. 2005; 14: 114-120PubMed Google Scholar] or Gleason [16Gleason T.G. New graft formulation and modification of the David reimplantation technique.J Thorac Cardiovasc Surg. 2005; 130: 601-603Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar] who use a “2 · h + 2” (h = average cusp height in mm) formula to select the proper proximal graft size, nor does David [17David T.E. Sizing and tailoring the Dacron graft for reimplantation of the aortic valve.J Thorac Cardiovasc Surg. 2005; 130: 243-244Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar]. In many patients, reducing the size of a dilated aortic annulus is an essential element of the operation to restore valvular competency; this is easily accomplished by necking down the proximal end of the large graft with several small plicating sutures [14Demers P. Miller D.C. Simple modification of “T. David-V” valve-sparing aortic root replacement to create graft pseudosinuses.Ann Thorac Surg. 2004; 78: 1479-1481Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar], taking care to calculate that this will be the external diameter of the aortic annulus, not the internal diameter. Being able to cut off the large graft above the top of the commissures facilitates visualizing the sinus rim reimplantation suture line (instead of sewing inside a long, small caliber “chimney” graft as in the T. David-I technique) and allows recreation of more optimal three-dimensional geometry of the sinuses and cusp hinge lines, especially in patients with MFS who have very tall commissures (upward of 5 cm in length) and a relatively bulky rim of aortic tissue contiguous with the hinge of the cusps [14Demers P. Miller D.C. Simple modification of “T. David-V” valve-sparing aortic root replacement to create graft pseudosinuses.Ann Thorac Surg. 2004; 78: 1479-1481Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar]. In recent years, I have shortened the free margin of one or more aortic cusps in more than 75% of cases; this is done using a 6-0 Gore-Tex (W.L. Gore & Assoc, Flagstaff, Arizona) suture to imbricate the central portion of the cusp (the nodulus of Aranti) to correct preexistent cusp prolapse (associated with eccentric AR) or to craft an equal and high coaptation level for all three cusps (striving to create greater than 5 mm of cusp coaptation zone) or when making a large annulus much smaller inadvertently creates prolapse, usually involving the right or noncoronary cusp.There has been only 1 operative death (secondary to complications arising from a nondominant right coronary artery anastomosis in a teenager who also required concomitant total arch replacement) among the first-time cases, and 1 late death (suicide). Two patients have required reoperation owing to recurrent AR: a woman, 7 years after a T. David-I (cusp edges thickened and retracted), and a very young man with MFS who had marked annular dilatation 2 years after a Yacoub remodeling procedure. Progressive mitral regurgitation prompted reoperation in a third patient. At 10 years, we are very satisfied with the durability of the David reimplantation method; all patients have zero or 1+, nonprogressive AR on serial follow-up echocardiograms. Conversely, some of the adult Yacoub patients do have 2+ AR, but it is not yet progressing. Postoperatively, we assessed aortic root and downstream aortic flow velocities and flow patterns using phase contrast, time-resolved magnetic resonance imaging in patients after various types of valve-sparing aortic root replacement procedures and in normal volunteers [18Markl M. Draney M.T. Miller D.C. et al.Time-resolved three-dimensional magnetic resonance velocity mapping of aortic flow in healthy volunteers and patients after valve-sparing aortic root replacement.J Thorac Cardiovasc Surg. 2005; 130: 456-463Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar]. This work determined that the flow conditions after a T. David-V or T. David-V Stanford modification procedure more closely mimicked that seen normally, and eliminated the tightly helically wound, very fast velocity flow in the distal ascending aorta seen after the T. David-I operations. This more physiologic flow may or may not translate into better valve durability over the long term, but should reduce the abnormal shear stresses imposed on the arch and proximal descending thoracic aorta downstream.In summary, the surgeon must always put the patient’s welfare first and foremost. The key question is not if the valve can be spared, but will the preserved aortic valve function well for 10 years or longer? Seasoned surgical judgment and judicious patient selection are essential in deciding whether valve-sparing root replacement is the best option for any given patient. It is also implicit, but needs to be reemphasized to the patients, that a patient who chooses valve-sparing root replacement must understand and accept that a second operation may be necessary in the future. The future results of the National Marfans Foundation prospective aortic root replacement registry will tell us which specific technique is best for patients with MFS. Patients should seek out a cardiac surgeon who has considerable personal experience with valve-sparing aortic root replacement, as this procedure remains more art than science and is most unforgiving of small technical errors in dynamic three-dimensional geometry. Doctor Miller discloses that he has financial relationships with Medtronic Heart Valve Division, Inc., Edwards Lifesciences, LLP, Boston Scientific Corp., 3F Corporation, and St. Jude Medical, Inc Doctor Miller discloses that he has financial relationships with Medtronic Heart Valve Division, Inc., Edwards Lifesciences, LLP, Boston Scientific Corp., 3F Corporation, and St. Jude Medical, Inc Doctor Miller discloses that he has financial relationships with Medtronic Heart Valve Division, Inc., Edwards Lifesciences, LLP, Boston Scientific Corp., 3F Corporation, and St. Jude Medical, Inc Since Sir Magdi Yacoub pioneered aortic root “remodeling” in 1979 [1Yacoub M. Fagan A. Stassano P. Radley-Smith R. Results of valve conserving operations for aortic regurgitation.Circulation. 1983; 68 ([Abstract]): 321PubMed Google Scholar, 2Sarsam M.A.I. Yacoub M. Remodeling of the aortic valve annulus.J Thorac Cardiovasc Surg. 1993; 105: 435-438PubMed Google Scholar] and Tirone David [3David T.E. Feindel C.M. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta.J Thorac Cardiovasc Surg. 1992; 103: 617-621PubMed Google Scholar] followed in 1988 with the “reimplantation” method to preserve the patient’s native aortic valve when replacing an aortic root aneurysm with a graft, both procedures have been demonstrated to be applicable to many patients with aortic root pathology and aortic regurgitation (AR), including those with the Marfan syndrome (MFS) [4Miller D.C. Valve-sparing aortic root replacement in patients with the Marfan syndrome.J Thorac Cardiovasc Surg. 2003; 125: 773-778Abstract Full Text Full Text PDF PubMed Scopus (188) Google Scholar]. The hope has been that cumulative valve-related morbidity and mortality would be lower after a valve-sparing operation compared with after composite valve grafting utilizing a mechanical prosthesis and indefinite warfarin anticoagulation, which represents the surgical “gold standard.” While preserving the native aortic valve liberates the patient from the need for life-long anticoagulation, the unanswered question has been valve durability after a Yacoub or David procedure. The popularity of valve-sparing aortic root replacement has escalated rapidly recently owing in no small part to patient demand, but the key question remains [4Miller D.C. Valve-sparing aortic root replacement in patients with the Marfan syndrome.J Thorac Cardiovasc Surg. 2003; 125: 773-778Abstract Full Text Full Text PDF PubMed Scopus (188) Google Scholar]: How many years without warfarin will the valve last before a second operation might become necessary? This also is the rationale for the ongoing international registry in 22 North American and European centers sponsored by the National Marfans Foundation comparing composite valve grafting with various types of valve-sparing aortic root replacement procedures in MFS patients. In the interim, what do we know with any modicum of certainty? Based on currently available knowledge, valve durability unfortunately has not been universally satisfactory, prompting some well-known centers to argue that valve-sparing aortic root replacement should be abandoned or limited just to those patients who cannot safely receive anticoagulation therapy [5Zehr K.J. Matloobi A. Connolly H.M. Orszulak T.A. Puga F.J. Schaff H.V. Surgical management of the aortic root in patients with Marfan syndrome.J Heart Valve Dis. 2005; 14: 121-129PubMed Google Scholar, 6Zehr K.J. Orszulak T.A. Mullany C.J. et al.Surgery for aneurysms of the aortic root—a 30-year experience.Circulation. 2004; 110: 1364-1371Crossref PubMed Scopus (160) Google Scholar]. Further, the mortality rate for valve-sparing aortic root replacement has been excessive in other centers [7Hess Jr, P.J. Klodell C.T. Beaver T.M. Martin T.D. The Florida sleeve: a new technique for aortic root remodeling with preservation of the aortic valve and sinuses.Ann Thorac Surg. 2005; 80: 748-750Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar]. These problems are related in part to surgeon inexperience in aortic root surgery, surgeon unfamiliarity with the pathological anatomy, lack of conceptual understanding of the procedure by surgeons (eg, unnecessarily using pledgeted sutures inside the left ventricular outflow tract tied firmly to the graft), and false surgical pride. First, the 15- to 20-year results after composite valve grafting in patients with MFS were shown by Gott and colleagues [8Gott V.L. Greene P.S. Alejo D.E. et al.Replacement of the aortic root in patients with Marfan’s syndrome.N Engl J Med. 1999; 340: 1307-1313Crossref PubMed Scopus (501) Google Scholar] to be outstanding if operation was performed electively before acute aortic dissection or aortic rupture. Morbidity attributed to anticoagulant-related complications was rare, and the thromboembolic and prosthetic valve endocarditis rates were low. Thus, the clinical performance bar has been set very high: the incidence of valve-related morbidity and mortality after valve-sparing aortic root replacement must equal or exceed these standards [4Miller D.C. Valve-sparing aortic root replacement in patients with the Marfan syndrome.J Thorac Cardiovasc Surg. 2003; 125: 773-778Abstract Full Text Full Text PDF PubMed Scopus (188) Google Scholar]. Either type of valve-sparing aortic root replacement is safe, fairly reproducible, and associated with reasonable results in selected patients, at least in the hands of certain surgeons. The surgical learning curve, however, is very steep and unforgiving. If the aortic valve cusps are not pathologically damaged, the vast majority of these valves can be conserved; relative contraindications in the past (eg, very large aortic annulus, severe AR or eccentric AR jet due to cusp prolapse, or both, and so forth) have been overcome with new surgical techniques. The outcomes at 10 years and beyond notwithstanding excellent survival statistics, however, are not ideal. Even in the best surgical centers, 25% to 30% of MFS patients undergoing valve-sparing aortic root replacement have 3+/4+ recurrent AR at 10 years, and small numbers have required aortic valve replacement (AVR) [9de Oliveira N.C. David T.E. Ivanov J. et al.Results of surgery for aortic root aneurysm in patients with the Marfan syndrome.J Thorac Cardiovasc Surg. 2003; 125: 789-796Abstract Full Text Full Text PDF PubMed Scopus (204) Google Scholar]. The long-term durability data are still scanty and follow-up is limited, but most surgical authorities today use the David reimplantation method (including creation of Dacron pseudosinuses) since one can adjust annulus size to whatever is ideal for that individual patient and the annulus cannot dilate postoperatively [4Miller D.C. Valve-sparing aortic root replacement in patients with the Marfan syndrome.J Thorac Cardiovasc Surg. 2003; 125: 773-778Abstract Full Text Full Text PDF PubMed Scopus (188) Google Scholar]. The incidence of postoperative bleeding is higher after a Yacoub procedure [9de Oliveira N.C. David T.E. Ivanov J. et al.Results of surgery for aortic root aneurysm in patients with the Marfan syndrome.J Thorac Cardiovasc Surg. 2003; 125: 789-796Abstract Full Text Full Text PDF PubMed Scopus (204) Google Scholar]. Professor Sir Magdi Yacoub’s personal results in 82 MFS patients showed that 17% required reoperation by 10 years, and an additional 22% had moderate AR at the time of last follow-up (mean, 5.5 years; median, 3) [10Birks E.J. Webb C. Child A. Radley-Smith R. Yacoub M.H. Early and long-term results of a valve-sparing operation for Marfan syndrome.Circulation. 1999; 100: 29-35Google Scholar]. Discouraging results at Johns Hopkins in children and young adults after Yacoub procedures prompted Cameron to switch to the David technique in 2002 [11Cattaneo S.M. Bethea B.T. Alejo D.E. et al.Surgery for aortic root aneurysm in children: a 21-year experience in 50 patients.Ann Thorac Surg. 2004; 77: 168-176Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar]. The Hannover (Germany) 1993 to 2005 experience (exclusively T. David-I reimplantation using a cylindrical graft) totals 325 patients, 59 of whom had MFS [12Kallenbach K. Karck M. Pak D. et al.Decade of aortic valve sparing reimplantation: are we pushing the limits too far?.Circulation. 2005; 112: 253-259Google Scholar]. Freedom from AVR was 80% ± 9% at 10 years, but MFS was a risk factor for late AVR. David’s most recent updated experience in 220 patients (40% with MFS; mean age, 46 years; average follow-up, 5.2 ± 4 years) revealed an operative mortality of 1% (3 of 220) and overall freedom estimate from 3+ or 4+ AR of 85% ± 5% at 10 years (94% ± 4% after David reimplantation versus 75% ± 10% after Yacoub remodeling, p = 0.04) [13David T.E. Feindel C.M. Webb G.D. Colman J.M. Armstrong S. Maganti M. Long term results of aortic valve sparing operations for aortic root aneurysm.J Thorac Cardiovasc Surg. 2006; 132: 347-354Abstract Full Text Full Text PDF PubMed Scopus (232) Google Scholar]. Late AVR was necessary in 5 patients (freedom from AVR at 10 years was 95% ± 3%). David and colleagues [13David T.E. Feindel C.M. Webb G.D. Colman J.M. Armstrong S. Maganti M. Long term results of aortic valve sparing operations for aortic root aneurysm.J Thorac Cardiovasc Surg. 2006; 132: 347-354Abstract Full Text Full Text PDF PubMed Scopus (232) Google Scholar] concluded that the reimplantation method proffers better durability; however, it should be noted that multivariable analysis using propensity score matching or case control statistical techniques were not employed to test this hypothesis rigorously, as the Yacoub and David patient cohorts differed. The basis for my opinion and prejudices rests on our 13-year experience at Stanford, where we have performed 134 valve-sparing aortic root replacement procedures between July 1993 and April 2006. Seventy-two patients had MFS. There were a total of 120 T. David reimplantations and 14 Yacoub remodeling procedures (Fig 1). We started with the T. David-I operation and then tried the Yacoub technique in the late 1990s; even though the remodeling approach is quicker and saves one suture line, one reoperation due to annular dilatation and recurrent AR prompted abandoning the Yacoub approach after 12 adult cases. We then reverted to the T. David-IV technique, and in May 2001 (the same month Dr David independently but similarly began using a larger graft necked down both proximally at the annulus and distally at the sinotubular junction) adopted the T. David-V method. In December 2002, we developed our simplified T. David-V technique (“Stanford modification”) using one large graft and one small graft, which creates large, billowing Dacron pseudosinuses [14Demers P. Miller D.C. Simple modification of “T. David-V” valve-sparing aortic root replacement to create graft pseudosinuses.Ann Thorac Surg. 2004; 78: 1479-1481Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar]. Twenty-five cases were performed in 2005 and 12 in the first 4 months of this year, which extrapolates to a total of 30 to 40 cases in 2006. I continue to prefer fabricating a custom-designed “sinus prosthesis” using two grafts because every important dimension (ie, new annular diameter, sinus diameter, sinus and commissure height, and sinotubular junction diameter) can be individualized for each patient; the commercially available sinus graft developed by De Paulis does not provide this unlimited degree of flexibility. The difference in sizes between the large and small grafts has varied from 8 to 12 mm, with the large graft diameter ranging from 30 to 36 mm (one was 38 mm). On the other hand, one can oversize the proximal graft excessively; I do not concur with Aybek and colleagues [15Aybek T. Sotiriou M. Wöhleke T. et al.Valve opening and closing dynamics after different aortic valve-sparing operations.J Heart Valve Dis. 2005; 14: 114-120PubMed Google Scholar] or Gleason [16Gleason T.G. New graft formulation and modification of the David reimplantation technique.J Thorac Cardiovasc Surg. 2005; 130: 601-603Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar] who use a “2 · h + 2” (h = average cusp height in mm) formula to select the proper proximal graft size, nor does David [17David T.E. Sizing and tailoring the Dacron graft for reimplantation of the aortic valve.J Thorac Cardiovasc Surg. 2005; 130: 243-244Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar]. In many patients, reducing the size of a dilated aortic annulus is an essential element of the operation to restore valvular competency; this is easily accomplished by necking down the proximal end of the large graft with several small plicating sutures [14Demers P. Miller D.C. Simple modification of “T. David-V” valve-sparing aortic root replacement to create graft pseudosinuses.Ann Thorac Surg. 2004; 78: 1479-1481Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar], taking care to calculate that this will be the external diameter of the aortic annulus, not the internal diameter. Being able to cut off the large graft above the top of the commissures facilitates visualizing the sinus rim reimplantation suture line (instead of sewing inside a long, small caliber “chimney” graft as in the T. David-I technique) and allows recreation of more optimal three-dimensional geometry of the sinuses and cusp hinge lines, especially in patients with MFS who have very tall commissures (upward of 5 cm in length) and a relatively bulky rim of aortic tissue contiguous with the hinge of the cusps [14Demers P. Miller D.C. Simple modification of “T. David-V” valve-sparing aortic root replacement to create graft pseudosinuses.Ann Thorac Surg. 2004; 78: 1479-1481Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar]. In recent years, I have shortened the free margin of one or more aortic cusps in more than 75% of cases; this is done using a 6-0 Gore-Tex (W.L. Gore & Assoc, Flagstaff, Arizona) suture to imbricate the central portion of the cusp (the nodulus of Aranti) to correct preexistent cusp prolapse (associated with eccentric AR) or to craft an equal and high coaptation level for all three cusps (striving to create greater than 5 mm of cusp coaptation zone) or when making a large annulus much smaller inadvertently creates prolapse, usually involving the right or noncoronary cusp. There has been only 1 operative death (secondary to complications arising from a nondominant right coronary artery anastomosis in a teenager who also required concomitant total arch replacement) among the first-time cases, and 1 late death (suicide). Two patients have required reoperation owing to recurrent AR: a woman, 7 years after a T. David-I (cusp edges thickened and retracted), and a very young man with MFS who had marked annular dilatation 2 years after a Yacoub remodeling procedure. Progressive mitral regurgitation prompted reoperation in a third patient. At 10 years, we are very satisfied with the durability of the David reimplantation method; all patients have zero or 1+, nonprogressive AR on serial follow-up echocardiograms. Conversely, some of the adult Yacoub patients do have 2+ AR, but it is not yet progressing. Postoperatively, we assessed aortic root and downstream aortic flow velocities and flow patterns using phase contrast, time-resolved magnetic resonance imaging in patients after various types of valve-sparing aortic root replacement procedures and in normal volunteers [18Markl M. Draney M.T. Miller D.C. et al.Time-resolved three-dimensional magnetic resonance velocity mapping of aortic flow in healthy volunteers and patients after valve-sparing aortic root replacement.J Thorac Cardiovasc Surg. 2005; 130: 456-463Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar]. This work determined that the flow conditions after a T. David-V or T. David-V Stanford modification procedure more closely mimicked that seen normally, and eliminated the tightly helically wound, very fast velocity flow in the distal ascending aorta seen after the T. David-I operations. This more physiologic flow may or may not translate into better valve durability over the long term, but should reduce the abnormal shear stresses imposed on the arch and proximal descending thoracic aorta downstream. In summary, the surgeon must always put the patient’s welfare first and foremost. The key question is not if the valve can be spared, but will the preserved aortic valve function well for 10 years or longer? Seasoned surgical judgment and judicious patient selection are essential in deciding whether valve-sparing root replacement is the best option for any given patient. It is also implicit, but needs to be reemphasized to the patients, that a patient who chooses valve-sparing root replacement must understand and accept that a second operation may be necessary in the future. The future results of the National Marfans Foundation prospective aortic root replacement registry will tell us which specific technique is best for patients with MFS. Patients should seek out a cardiac surgeon who has considerable personal experience with valve-sparing aortic root replacement, as this procedure remains more art than science and is most unforgiving of small technical errors in dynamic three-dimensional geometry. The author is supported by R01 Research Grants HG29589 (1982–2008) and Health HL67025 (2001–2010) from the National Institutes of Health.