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AI Class Type I
Type II
Type III
Patch repair
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Mechanism
Repair
Techniques
Normal cusp motion with FAA dilatation or cusp perforation
Ia Ib Ic Id
STJ Remodeling
Ascending aortic
graft
VSRR
Reimplantation
or
Remodeling+SCA
SCA
or
External Ring
Patch Repair
Autologous or
bovine
pericardium
Cusp Prolapse
Leaflet Repair
Triangular
resection
Free margin
plication or
resuspension
Cusp Restriction
Leaflet Repair
Shaving
Decalcification
Patch repair
Fig. 1 Repair-oriented functional classication of aortic insufciency (AI) with description of
disease mechanisms and repair techniques used. Non-shaded columns are the focus of this review.
FA A functional aortic annulus, STJ sinotubular junction, VSRR valve sparing root replacement,
SCA subcommissural annuloplasty
Type II AI is due to cusp prolapse. In patients with acute Type A aortic dissection
this may be due to chronic underlying cusp pathology in the form of excessive cusp
tissue or due to acute extension of the dissection into the root causing commissural
disruption. Prolapse may also be unmasked or induced when a dilated STJ is
restored to normal dimensions.
Type III AI is due to cusp restriction from calcication, thickening, or brosis of
the cusps. In the context of acute Type A aortic dissection, most often these are
chronic underlying ndings found in a bicuspid, degenerative, or rheumatic valve
that are unrelated to the acute dissection. Nevertheless, all lesions found at the time
of surgery need to be addressed.
Aortic Valve Repair inAcute Aortic Dissection: Selection
Patient selection for aortic root intervention and AV repair in patients presenting
with AI and acute Type A dissection hinges on a combination of factors: the patient’s
condition, the surgeon’s expertise, and anatomic factors.
The rst factor in decision-making is the patient’s condition upon presentation.
The basic principle is that emergency acute type A dissection surgery is a life-saving
surgery. Therefore, a hemodynamically unstable patient or one presenting with end
organ malperfusion and dysfunction may benet from a more conservative approach
with the shortest ischemic time that saves the patient’s life, despite the risk of future
re-intervention.
The second factor is surgeon expertise. If limited surgical experience is a factor,
then a Bentall procedure may be safer than a valve-sparing root procedure.
Furthermore, without a real indication to replace the aortic root such as intimal
injury, dissection ap, or dilatation of the aortic root >45mm, a simple aortic valve
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replacement (AVR) and a supracoronary ascending aorta replacement may be the
safest procedure. In many of these decision-making scenarios, the age of the patient
and the risk of re-intervention must be weighed against the increased risk of mortality from a more complex operation.
The third factor relies on understanding the mechanism of AI in terms of anatomy and physiology and deciding whether there is an indication for aortic root and
AV intervention and if the conditions are favorable for AV repair. The pre-operative
CT scan is the surgeon’s rst glimpse at anatomy. It shows the extent of the dissection (whether it extends into the aortic root) as well as the dimension of the aorta at
various levels (ascending, STJ, sinuses of Valsalva). An underlying aneurysmal
ascending aorta sparing the root versus one that involves the aortic root may be the
rst indication of the extent of surgery required. In most patients, the aortic root and
valve can be safely spared and repaired using aortic valve resuspension [22].
Next, an intra-operative TEE corroborates the anatomic factors seen on CT.In addition, it provides physiological information about the mechanism of AI.Key aspects to
consider include jet origin and direction, end-diastolic measurements of the VAJ, STJ,
and Sinuses of Valsalva, cusp thickness, mobility, and presence of calcication.
Despite gathering essential information from CT and TEE, intra-operative visual
inspection remains the nal arbiter on the reparability of the AV.Cusp tissue quality
is perhaps the most important factor in deciding whether preservation and repair of
the AV is feasible. Heavily calcied or brotic cusps usually preclude repair.
Similarly, severely dilated STJs are associated with stress fenestrations along the
commissures, which makes a durable AV repair unlikely. Decreased cusp geometric
height (<16mm) is another marker of cusp restriction that may preclude a good AV
repair. Sievers type 1 bicuspid AVs [25] with commissural angles <140° also can be
challenging to repair and may require techniques such as tricuspidization. In the
context of a root aneurysm and one of the above cusp ndings, a valve replacement
may be the preferred technique [26]. Finally, visual inspection is essential in cases
of a prolapsing ascending intimal ap. Relying on TEE may be difcult as the prolapsing ap interacting with the AV may be the only cause of AI or there may be
other underlying mechanisms for AI obscured by the ap.
T. Al-Atassi and M. Boodhwani
Aortic Valve Repair inAcute Aortic Dissection: Techniques
Type I AI lesions are most frequently due to dilatation of the various components of
the FAA and may occur in isolation or with associated cusp disease.
Repair ofType Ia AI
An acute aortic dissection is associated with a rapid increase in the size of the
affected aorta [27]. When this rapid increase is greater than 30% of baseline, STJ
dilatation alone may be sufcient to cause AI [28]. Type Ia aortic valve insufciency
ab
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Fig. 2 (a) Sizing of aortic prosthesis. Traction is applied to the commissural retraction sutures to
place the valve in physiologic closing position with adequate cusp coaptation. The sinotubular
junction is sized in this position. Oversizing the prosthesis can lead to central regurgitation,
whereas undersizing can induce cusp prolapse. (b) Orientation and spacing. The anastomosis is
performed at the level of the sinotubular junction starting with three separate sutures, one at each
commissure. This ensures correct orientation of the prosthesis and appropriate spacing. Unequal
spacing between commissures can induce cusp prolapse. Reprinted with permission from
Boodhwani, M and El Khoury, G. Aortic Valve Repair. Operative Techniques in Thoracic and
Cardiovascular Surgery. Volume 14, Issue 4, Winter 2009:266–280.
is due to dilatation of the ascending aorta with concomitant STJ dilatation leading
to a central cusp coaptation defect and ensuing central regurgitant jet. In milder
cases without associated cusp disease, cusp tissue quality remains intact and the
valve can easily be repaired. However, a chronic, severely dilated STJ will often be
associated with stress fenestrations along the commissures. If large fenestrations
exist in multiple cusps and especially if they are within the coaptation zone of the
valve, it may be best to replace the valve. The former case can be corrected by
replacing the ascending aorta and remodeling the STJ using a Dacron tube graft.
Sizing of the aortic prosthesis is performed by placing three commissural retraction
sutures and applying traction to place the valve in physiologic closing position. The
STJ is sized in that position using a valve sizer (Fig.2). Accurate sizing is essential
as oversizing can lead to central AI and undersizing can lead to cusp prolapse. The
anastomosis is performed at the level of the STJ using the three separate commissural sutures, ensuring correct orientation and appropriate spacing between the
commissures. Uneven spacing between the commissures can induce cusp prolapse.
When the dissection ap extends to the STJ, then either one or two layers of Teon
felt strip can initially be added on the inside and outside of the aorta to bring back
together the layers of the aortic wall and the commissural sutures can be pledgeted.
In cases of signicant AI and widening of the interleaet triangle, the surgeon may
need to add a subcommissural annuloplasty using braided sutures (Fig.3). The rst
arm of the pledgeted braided suture is passed from the aortic to the ventricular side,
in the interleaet triangle, and comes back out to the aortic side at the same level.
The second arm of the suture is passed in a similar fashion below the rst. A free
pledget is added and the suture is tied, reducing the width of the interleaet triangle
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Fig. 3 Reprinted with permission from Boodhwani, M and El Khoury, G. Aortic Valve Repair.
Operative Techniques in Thoracic and Cardiovascular Surgery. Volume 14, Issue 4, Winter 2009:
266–280.
T. Al-Atassi and M. Boodhwani
and increasing the coaptation surface of the valve leaets. This is performed at each
commissure. These sutures are usually placed at midcommissural height, except at
the noncoronary/right coronary commissure, where it should be placed higher to
avoid the membranous septum and conduction tissue. A sub-commissural annuloplasty, or Cabrol stitch, should NOT be performed within a dissected aortic root as
it will further exacerbate the dissection and potentially cause new tears in an already
dissected aorta. This technique should be reserved for roots that are completely intact.
Repair ofType Ib AI
Type Ib lesions are due to dilatation of the VAJ and STJ leading to a central cusp
coaptation defect and regurgitant jet. In the context of acute Type A dissection, the
surgeon should consider replacing the aortic root when it is >45mm in diameter,
when there is an entry tear or signicant dissection involving the root, and in genetic
syndromes. If there is only limited dissection of the aortic root and no tears in the
root, then it may be preserved in select cases. If the cusps are heavily calcied,
brotic, or have fenestrations and in Sievers type 1 bicuspid AVs with commissural
angles <140°, the surgeon should proceed with a Bentall procedure. Otherwise, a
valve-sparing root replacement (VSRR) is reasonable in expert hands. Details of
Bentall and VSRR in type A dissection are discussed in other chapters of this book.
Briey, for VSRR, either the reimplantation or remodeling plus annuloplasty technique can be used. However, an important disadvantage of the remodeling technique is the need to sew the graft to a potentially dissected aortic rim and the
resulting risk of bleeding complications. In contrast, since the reimplantation technique anchors the graft below the aortic valve, in an area unaffected by the dissection, it can be a safe procedure from a hemostatic perspective. Remodeling of the
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aortic root is also postulated to better preserve annular dynamics during the cardiac
cycle, though the impact on clinical outcome remains uncertain [29]. However,
long-term results of the remodeling technique have not been as good as the reimplantation technique, especially in patients with aortic root aneurysms associated
with bicuspid AV insufciency and genetic syndromes [30–33]. Lastly, there is little
published data on the use of the remodeling technique in acute aortic dissection. In
addition to the root replacement, the cusps need to be assessed after the root is
replaced and possible adjunctive cusp repair techniques may be used at that point.
These techniques are further discussed under type II and type II lesions.
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Type Ic AI Repair
Type Ic lesions are due to dilatation of the VAJ due to dilatation of the left ventricle.
This is uncommon in acute type A dissections, unless there was an underlying
chronic left ventricular pathology leading to dilatation. Severe VAJ dilation in the
context of acute dissection may be best treated with a reimplantation procedure,
when indicated.
Type Id AI Repair
This lesion typically includes cusp defects due to large fenestrations or defects from
endocarditis. However, in the context of acute Type A dissection there is a more
frequent scenario of a prolapsing ap from the ascending aorta that interferes with
the functioning of the AV.The valve and root may be completely normal, but the
prolapsing ap interacts with the AV and sometimes protrudes into the left ventricular outow tract, leading to AI [34]. This is easily repaired with a supracoronary
ascending aorta replacement. However, the surgeon must be careful in assessing for
the presence of other lesions that may be difcult to see on TEE, which are masked
by the prolapsing ap.
Type II AI Repair
Type II lesions are due to cusp prolapse and leads to an eccentric regurgitant jet seen
on TEE.One or more cusps will coapt lower than the usual midpoint between the
STJ and VAJ.It is the most frequent cusp pathology and may be due to underlying
intrinsic cusp pathology or in the context of VSRR using the reimplantation technique to reduce the annular dimension. Central free margin plication using a small
caliber Prolene suture placed in the center of the free margin can correct slight cusp
prolapse [35]. This suture plicates, shortens, and reduces the length and therefore
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raises the height of the prolapsing cusp. For slightly larger degrees of prolapse, an
alternative technique is free margin resuspension performed by passing a PTFE
suture over and over the free margin and exteriorizing the suture at the commissures. Pulling on this suture has the effect of performing multiple plications along
the free margin thereby shortening and raising it [35]. For severely prolapsing cusps
with excess tissue, a larger degree of correction may be needed by resecting a small
portion of the cusp with primary reapproximation.
T. Al-Atassi and M. Boodhwani
Type III AI Repair
Type III lesions are due to cusp motion restriction. This is usually caused by underlying
cusp pathology and is unrelated to the acute type A dissection. Nevertheless, the lesion
must be addressed if it is causing signicant AI at the time of surgery. This may be due
to a calcied or brotic cusp in degenerative and rheumatic valves or in type I bicuspid
aortic valves with conjoint cusp restriction due to a brous or calcied raphe. If the valve
pathology is degenerative or rheumatic, then the valve should be replaced. For bicuspid
valves, shaving the brous raphe may be all that is needed. If shaving is not adequate
then resection of the raphe with primary reapproximation can be performed if there is
sufcient cusp tissue. Alternatively, resection and cusp restoration with patch material
may be required if there is insufcient cusp tissue left for primary reapproximation.
Patch material has also been used for tricuspidization of bicuspid valves. However, the
use of patch material in AV repair is a predictor or long-term failure [36]. In addition, if
the surgeon lacks experience or complex bicuspid valve repair is required, an aortic
valve replacement should be performed.
Aortic Valve Repair inAcute Aortic Dissection: Outcomes
The decision to intervene on the aortic root and to repair or replace the aortic valve
can be a complex one and requires consideration of numerous factors. The primary
objective of the operation is to save the patient’s life by eliminating potentially fatal
complications. Intervening on the aortic root without a clear indication and attempts
at AV repair that signicantly prolong myocardial ischemic time, fail and require
AV re-exploration are undesirable and can increase the risk of the operation. On the
other hand, the risk of prosthetic valve-related events and lifelong anticoagulation
may complicate future management of residual aortopathy in these patients.
Although aortic valve repair and leaving the native aortic root increase the risk of
long-term reintervention, these patients often have competing risks of morbidity
and mortality related to their aortopathy, making such risks less relevant.
Furthermore, the cases requiring re-intervention can be done in a more elective and
controlled setting. Data on mid- and long-term valvular outcomes shows that the
risk of proximal re-intervention after a dissection repair is low. All studies around
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these topics are retrospective and have inherent limitations related to heterogeneity
of patient populations, surgeon experience, myriad of surgical techniques and permutations, and biases in surgeons’ complex decision-making processes.
When the aortic root is not dilated and does not have an entry tear, then AV repair
through an AV resuspension has good immediate outcomes even with severe AI at
presentation [37]. Long-term freedom from reoperation rates at 10 years on repaired
AVs range from 69% to 95% [38–40]. Sievers etal. found that a valve-sparing root
repair strategy has similar 30-day mortality and 15-year freedom from reoperation
compared to valve sparing root replacement using reimplantation or remodeling
techniques [41]. In patients without an indication to replace the root, they found a
valve-sparing root repair strategy as a less complex and faster technique in this
emergent setting. Others have argued that given the similar short- and long-term
results of a root replacement strategy compared with a supracoronary ascending
replacement and AV resuspension, then one should perform the “curative proximal
repair” by replacing the root, whether by a composite valve conduit (Bentall procedure) or a valve sparing root replacement [42, 43].
A contemporary meta-analysis of AV preservation and repair in acute type A dissection evaluated 2402 patients in 19 observational studies [22]. Early pooled mortality was 19% with a late estimated mortality pooled rate of 4.7%/patient-year.
From this data the survival estimates at 5 and 10 years were 58% and 34%, respectively. In the 13 studies reporting late AV re-intervention, the pooled rate was 2.1%/
patient-year, with a 5- and 10-years freedom from AV reintervention of 89% and
79%, respectively. The composite outcome of thromboembolism and bleeding had
a pooled rate of 1.4%/patient-year. This study highlighted the limited long-term
survival of acute type A dissection patients, moderate risk of reoperation and low
risk of valve-related complications in preserved valves.
Conclusions
Acute type A dissection is a complex, life-threatening disease with multiple considerations for management. Adding to this complexity, decision-making related
to the aortic valve in acute type A dissection needs to factor in the perioperative
risks of morbidity and mortality, which may be affected by the patient’s stability
at presentation, procedural complexity, and the surgeon expertise, as well as competing risks of late mortality related to residual aortopathy or other comorbidities.
Other important considerations include the incidence of valve-related events and
risk of late aortic valve reoperation. In carefully selected patients, aortic valve
repair techniques can prove useful with similar outcomes to valve replacement in
expert hands.
Acknowledgements None.
Sources of fundingNone.
Conicts of Interest None declared.
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T. Al-Atassi and M. Boodhwani
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