Aortic valve reconstruction associated to ascending aorta tubular graft replacement in aortic incompetence by annuloaortic ectasia.

OBJECTIVE Aortic valve incompetence associated with severe aortic ectasia is usually treated by aortic valve and ascending aorta replacement. In cases of isolated aortic ectasia or in Type A aortic dissection the valve is often normal and the incompetence is just due to annular dilatation. Such conditions lead to the application of various valve-sparing surgical techniques, as described by Senning et al., showing the advantages of preservation of the native valve, but the disadvantage of a high technical complexity and a high incidence of recidivation. METHODS We describe a valve-sparing surgical procedure, which has the advantage of a direct and simple approach together with satisfying mid-term results. After the aortic bulb has been fully transected, the excessive wall tissue is resected by two or three triangular excisions just above the valve commissures. Wall excision was indicated in those patients with an aortic diameter exceeding 65 mm at the sino-tubular junction. Tissue excision should not exert tension on to the coronary ostia or excessively reduce aortic diameter. Three external Teflon strips, overriding each other, are placed around the aortic bulb and are included in the direct suture of the edges of the triangular excisions. They are fixed by a running suture over the free border of the bulb. Aortic valve commissures are resuspended when needed. In this way, the aortic bulb, with a competent valve, is wrapped in a prosthetic and inextensible graft. The aortic continuity is then re-established with the interposition of a tubular dacron graft. RESULTS From April 1990 to December 1995, 21 patients (mean age 48 years, range 32-70) scheduled for surgery for aortic valve incompetence associated with annuloaortic ectasia were treated with this technique. In one patient the procedure failed to achieve a satisfying valve competence and the valve was replaced. In another case a prolapse of the non-coronary cusp required reoperation with aortic valve replacement, without further complications. At follow-up time (mean 42 months, range 18-78), all patients were well and healthy, with control echoes showing no residual valve incompetence and with invariate bulb diameters at every successive examination. CONCLUSIONS Our experience shows that this new valve-sparing approach allows safe and persistent correction of aortic valve incompetence and annuloaortic ectasia although longer term follow up is needed.