Valve preservation in acute type A aortic dissection: 13-year experience

Aim. Aortic dissection is frequently complicated by regurgitation of the aortic valve resulting from leaflet prolapse or tearing of the annulus or leaflet. The authors have evaluated the results using the technique of aortic valve preservation in patients with acute type A aortic dissection (AAD). Methods. In a consecutive series of 79 AAD observed from January 1994 to September 2007, 51 (64.6%) presented aortic valve insufficiency (AI). All patients were emergency operated on via median sternotomy and femoral (46/79, 58.2%) or axillary artery-right atrium (33/79, 41.8%) cardiopulmonary bypass with 60 cases (75.9%) of antegrade selective cerebral perfusion. The dissected aorta was resected and the aortic valve was replaced in 2 patients/51 (3.9%) and was preserved in the remaining 49 cases as follows: 42 (85.7%) commissural resuspensions due to commissural prolapse, 3 (6.1%) resuspensions due to cusp prolapse, 3 (6.1%) commissural plication and 1 (2.1%) circumclusion due to annular dilatation. Results. The overall hospital mortality was 20.3% (16/79) with a percentage of 19.6% (10/51) in the AI group. 1 patient presented a type B dissection at 1 months and died after reoperation. The remaining 40 patients with a preserved native valve were followed by echocardiography and computed tomography (CT) (follow-up ranged from 3 to 165 months) with 4 late deaths. Twenty-six patients had absent or grade I AI (72.2%), 8 had grade II AI (22.2%) and 2 presented grade III or IV AI (5.6%). Actuarial freedom from significant AI was 96.2±2.4% and 94.2±2.3% at 5 and 10 years respectively. Conclusion. The experience with this technique demonstrates the effectiveness of valve conservative treatment within a vascular graft. The reconstruction of the sinotubular junction reducing annular dilatation with appropriated sized graft is obviously mandatory. Although this procedure is not applicable to every patient, we firmly believe that is a valid option when a morphologically intact valve is present.