What is the Aortic Root?

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1 Mohammad Shihata

2 What is the Aortic Root? The Aortic Root, represents the outflow tract from the left ventricle, provides the supporting structures for the leaflets of the aortic valve, and forms the bridge between the left ventricle and the ascending aorta. It extends from the basal attachments of the leaflets Within the left ventricle to the sinotubular junction

3 The Aortic Root Consists of : Aortic annulus Aortic cusps Aortic Sinuses Sinotubular Junction (STJ)

4 The Aortic Annulus has muscular attachments ( the muscular IVS ) 45% of the circumference and fibrous attachment ( fibrous septum and anterior mitral leaflet ) 55% of the circumference.

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9 Too small ( small annulus ) Too large ( Root Aneurysm ) Enlargement - Nicks ( Post. ) procedure - Manouguian ( Post.) Procedure - Konno ( Ant.) Procedure Replacement - Bentall Procedure - Ross Procedure Replacement + Enlargement - Ross Konno - Modified Ross Konno Replacement Bentall - Mechanical - Stented tissue - Stentless tissue Valve Sparing - Remodelling - Reimplantation

10 Root Abscess ( Endocarditis ) Type A Dissection Replacement - Bentall - Mechanical - Stented tissue - Stentless tissue +/- Mitral / LA Reconstruction Bentall - Mechanical - Stented tissue - Stentless tissue Valve Sparing - Remodelling - Reimplantation

11 Degenerative Connective Tissue Disorders Bicuspid Aortopathy Post Stenotic Chronic Dissections

12 Replacement of the Aortic root & Ascending Arota is indicated If the diameter is > 55mm, or >50mm in case of CTD or family history of dissections

13 Reimplantation ( David I) Remodelling ( Yacoub)

14 1- Aortic root dilatation secondary to ascending aortic aneurysm: The mechanism of aortic insufficiency in this disease state is a consequence of the dilatation of the sinotubular junction (STJ) with distraction at the commissures of the valve leaflets.

15 2-Annulo-aortic ectasia and connective tissue syndromesctd such as Marfan s and Ehlers-Danlos: The mechanism Is dilatation of the sinuses, the sinotubular junction, as well as the annulus, due to pathologic cystic medial necrosis. Interestingly, the leaflets tend to be spared.

16 3-Aortic root and ascending aortic dissection acute or chronic: in aortic dissection, there is dilatation of the sinotubular junction with either or both (a) acute distraction of the valve leaflets; and (b) unhinging and prolapse of the leaflets secondary to sinus wall dissection.

17 In 1992, David and Feindel published a series of 10 patients

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23 167 patients, 10 year follow up Survival (92%) Freedom from moderate to severe AI (94%) Freedom from Aortic reoperation (95%)

24 325 (David I), 59 Marfans 80% freedom from reoperation at 10y 8.5% late mortality

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26 Gold Standard for young patients ( < 65y ) Permanent Anti coagulation -Contraindications -Life style -Patient preference Higher risk for TE Most Durable Higher risk for infection ( or Re infection) In 1968, Bentall and De Bono reported (in a two page case report), a single patient treated with a composite graft and mechanical valve replacement of the aortic root and ascending aorta with coronary reimplantation

27 Improved Hemodynamics Ideal for Root Abscess Reduced infection (?) Low Thromboembolic Complications Availability Risk of Calcification ( >50% SVD in 20 y ) ( immune mediated? ) Homovital ( Fresh) Cryopreserved

28 0.2% Preserved in glutaraldehyde Polyester sewing cuff Alfa amino oleic acid ( anticalcification ) Zero net pressure fixation of the leaflets

29 Root Aneurysm 43.8% Small Annulus 45.2% Type A dissection 6.6% Root Abscess 4.4% Operative mortality 5.4% 100% freedom from TEC and SVD at 5y

30 Bach DS, Metras J, Doty JR, Yun KL, Dumesnil JG, Kon ND Freedom from structural valve deterioration among patients aged < 60 years undergoing Freestyle stentless aortic valve replacement. J Heart Valve Dis Nov;16(6):649-55;] 725 patients, 92.4% freedom from SVD at 12 years

31 57 Reoperations in 12 y ( ) 10 Freestyles, 2 SVD (7 & 9 years) & 8 Endocarditis Reop within 1 y was an independant risk factor for mortality

32 Sizes 21 mm - 27mm

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36 Care must be taken when excising the Pulmonary Autograft due to the close proximity of the Pulmonary valve to the left main and first septal perforator coronary arteries

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38 No Anticoagulation/ Thromboembolic complications Potential for Growth Improved hemodynamics Reduced risk of Endocarditis

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41 Scalloped ( Subcoronary ) Inclusion Cylinder Freestanding Root Supported Root

42 Subcoronary Inclusion Cylinder

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45 Two centres, 347 patients, ( Subcoronary ) 0.6% hospital mortality FU 3.9 +/- 2.7 years 95% freedom from all cause reoperation

46 487 patients 80% freedom from Aortic reoperation 84% freedom from Allograft reoperation 95% freedom from endocarditis 1 TEC

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