Carrel, Thierry

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Dr Bachet: At 3 o’clock in the morning on a Sunday, you get a radiologistthat makes you a CT scan in a few minutes? It must be good to be at BadNeustadt.Dr Urbanski: The CT angiography takes a few minutes. It’s normal.Dr Bachet: Well, anyway, we have to stop this discussion. But there is alittle point I want to address before closing the discussion. I don’t know if Iunderstood correctly, but you said that in some Marfan patients you don’tremove all the sinuses?Dr Urbanski: Yes.Dr Bachet: For me this is erroneous.Dr Urbanski: I demonstrated here.Dr Bachet: Marfan patients should have their root replaced systematically.Dr Urbanski: After 10 years, they’re still alive and the root is normal.Dr Bachet: Yes, but you had only three Marfan patients in your statistics.Wait until you have a few more.Dr Urbanski: As I said, each Marfan patient presents different root and leafpathology. And the role of the surgeon is to decide properly in which patientsthe root is replaced with a Bentall procedure and which are repaired.European Journal of Cardio-Thoracic Surgery 44 (2013) 444–445 EDITORIAL COMMENTdoi:10.1093/ejcts/ezt065 Advance Access publication 24 February 2013Selective sinus repair in acute type A dissectionThierry Carrel*Clinic for Cardiovascular Surgery, Bern University Hospital, Berne, Switzerland* Corresponding author. Clinic for Cardiovascular Surgery, Bern University Hospital, Freiburgstrasse, 3010 Berne, Switzerland. Tel: +41-31-6322375;e-mail: thierry.carrel@insel.ch (T. Carrel).Keywords: Aortic dissection • Aortic root repair • Valve preservation • Selective sinus replacementCurrently, aortic valve-preserving root replacement is gainingpopularity in selected younger patients with the tricuspid valveto avoid the requirement for lifelong anticoagulation. Differenttypes of procedures (aortic root remodelling according toM. Yacoub and reimplantation technique according to T. David)have been described and increasingly used in the electivesetting. Resuspension of the commissures of the aortic valve andgraft replacement of the supracoronary aorta represent the mostcommonly performed procedures for patients presenting withacute dissection type A. When doing them, the surgeon needsto be conﬁdent that the valve repair will be durable andthe sinuses of Valsalva will not dilate excessively over time. Thepresence of advanced valve pathology (leaﬂet calciﬁcations,commissural fusion or large fenestrations close to the commis-sures) is usually an indication for valve replacement.Urbanski et al. [1] report a series of 46 patients treatedbecause of acute aortic dissection type A in whom one-, two- ora three-sinus repair was performed in order to selectively repairthe dissected part of the aortic root and to avoid the use of anytype of glue. The authors have to be congratulated for the excel-lent early and long-term results obtained in a difﬁcult group ofpatients.Aortic root remodelling using a selective sinus repair wasreported by Stephen Westaby as early as 2002, where hedescribed this successful approach in 29 patients suffering fromatherosclerotic aneurysm of the aortic root and who were oper-ated on between 1995 and 2001 (Fig. 1) [2]. In this paper,Westaby et al. suggested that root dilatation begins in the non-coronary, then in the right coronary sinus. The left coronarysinus usually retains normal dimensions until a very advancedstage. Rather than employing aortic root replacement or theDavid procedure, Westaby et al. elected to replace the ascendingaorta and remodel the sinotubular junction and the involvedsinuses. The long-term follow-up of these patients revealed thataortic valve and root repair provided a durable repair andallowed the avoidance of a more radical aortic root replacementwith prosthesis-related complications.Although the approach described by Urbanski et al. is anattractive one, some critical points have to be emphasized:(i) It might be questionable to include very old patients for avalve-sparing technique since aortic valve replacementwith a bioprosthesis (or complete root replacement with abiological composite graft) might be the more straightfor-ward and secure treatment.(ii) It is difﬁcult to conﬁrm an important advantage with singleor double sinus repair with separate patches in Marfanpatients, because the latter suffer generally from a path-ology of the whole aortic root and should receive the mostcomplete root repair or replacement. With this in mind, itis surprising that a ‘partial’ repair did not lead to anyre-intervention on the aortic root.(iii) Whether a classical David reimplantation procedure, ora root repair with three separate patches is the betteroption for those patients with a circumferentially dissectedaortic root seems clear to me: the David procedure with aValsalva tube graft secured below the aortic annulus ensuresthe best stability of the aortic annulus on its whole circum-ference and should therefore be the preferred surgicaltechnique.(iv) Finally, the surgical treatment of acute aortic dissection typeA should remain the simplest possible, shortening the timespent on cardiopulmonary bypass as well as the myocardial-protected ischaemic time as much as possible. I personallyfound a clamp time of 106 min to be rather long for twoaortic anastomoses and a selective sinus repair.P.P. Urbanski et al. / European Journal of Cardio-Thoracic Surgery444In my institutional experience with 40–50 acute type A dissec-tions treated surgically per year, the proportion of suitablecandidates for such an approach is probably small. But it is truethat the majority of such patients have a proximal dissectioninto the non-coronary sinus, as the coronary ostia tend to limitthe circumferential propagation of the dissecting process aroundthe aortic root.I would personally not recommend selective sinus repair inyounger patients with annulo-aortic ectasia in whom the aorticannulus is severely dilated (>27–28 mm) and in those with bicus-pid valves.The main advantage of the technique described by Urbanskiet al. may be the better visualization of the annulus with a smallseparate piece of the graft to reconstruct the correspondingsinus, thus allowing precise stitches through the more solidtissue of the aortic annulus. One theoretical drawback of the se-lective sinus repair is that a single Dacron ‘pseudosinus’ is notreally created and, therefore, the closing stress of the corre-sponding leaﬂet is high, thus limiting, at least theoretically, leaﬂetdurability.Finally, a selective sinus repair may not avoid further ongoingdilatation of the native annulus, which is not ﬁxed on the wholecircumference like in a classical David reimplantation procedure,as this technique reinforces the whole annulus.REFERENCES[1] Urbanski PP, Hijazi H, Dinstak W, Diegeler A. Valve-sparing aortic rootrepair in acute type A dissection. How many sinuses have to be repairedfor curative surgery? Eur J Cardiothorac Surg 2013;44:439–44.[2] Westaby S, Saito S, Anastasiadis K, Moorjani N, Jin XY. Aortic root remod-eling in atheromatous aneurysms: the role of selected sinus repair. Eur JCardiothorac Surg 2002;21:459–64.[3] David TE, Armstrong S, Manlhiot C, Mc Crindle BW, Feindel CM.Long-term results of aortic root repair using the reimplantation tech-nique. J Thorac Cardiovasc Surg 2012; 10.1016/j.jtcvs.2012.11.075.Figure 1: Selective one- and two-sinus repair of the aortic root following thetechnique of Westaby by shaping the Dacron graft correspondingly (Westabyet al. [2]; reproduced with kind permission of Oxford University Press).AORTICSURGERYP.P. Urbanski et al. / European Journal of Cardio-Thoracic Surgery 445

Editorial Comment: Selective sinus repair in acute type A dissection

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