Aortic root replacement surgery with preservation of the native aortic valve has established itself as a solid alternative to Bentall surgery by avoiding the complications related to valve prostheses and lifelong anticoagulation required by mechanical valves. However, since its description over 30 years ago, unanswered questions remain, such as the role of the Valsalva sinuses (VS) and the sinotubular junction in the hemodynamics of the ascending aorta, as well as the importance of their preservation. Various modifications of the technique have been developed to maintain the anatomical structure of the aortic root, including the Valsalva graft—a specially designed Dacron graft developed by this team in Rome to achieve anatomical reconstruction of the aortic root.

In this article, the authors review 20 years of results using David’s technique with the “Valsalva graft.” This Dacron graft is specifically designed for these surgeries, featuring a wider lower portion to simulate the VS area that transitions to a smaller diameter conduit, mimicking a sinotubular junction. The authors analyzed a cohort of 265 patients over the past two decades, with an average follow-up exceeding 7 years (minimum 1 month, maximum 21 years). Survival, freedom from reintervention, and development of significant aortic insufficiency were assessed in this cohort. The surgical mortality was 0.8% (two cases), with a 3-month mortality of 0.8% (two cases). Cardiovascular event mortality remained stable across the years at 0.4% over 15 years. Total mortality was 13 deaths during the follow-up, accounting for 4.9% of the sample, with only 5 of these attributed to cardiovascular causes. Residual aortic insufficiency (grade ≥ 3+) was 5.9% at 5 years, stabilizing at 7.8% at both 10 and 15 years. Fourteen patients (5.4%) exhibited significant residual aortic insufficiency, with seven reoperations: two for infectious endocarditis and five for severe aortic insufficiency, maintaining a stable reintervention incidence from the fifth year, reaching 4.1% at 10 and 15 years, with a 15-year reintervention-free rate of 84.3%.

In a multivariable analysis to assess predictors of repair failure, the authors concluded that a suboptimal intraoperative outcome (defined as residual aortic insufficiency ≥ 2+) and leaflet repair (pre-caliper use era) were associated with an increased risk of significant aortic insufficiency development over the follow-up period.

COMMENTARY:

In recent years, aortic valve preservation has gained popularity. Techniques developed over three decades ago have evolved. Thanks to data collection and patient follow-up, analyses confirm excellent short- and long-term results. Recent discussions focus on preserving or simulating the Valsalva sinus region and the sinotubular junction. Although no studies show a clear survival or durability advantage for these patients, imaging and animal studies suggest that preserving the sinotubular junction may benefit leaflet motion and generate more physiological flow throughout the aortic root, potentially impacting repair durability.

This study presents 15-year outcomes of aortic valve reimplantation using the “Valsalva graft,” a specially designed Dacron tubular graft to simulate the creation of neo-sinuses of Valsalva. The results are outstanding, with very low operative mortality and long-term cardiovascular mortality limited to five cases, alongside a reintervention rate under 5% at 15 years. The authors highlight the significance of residual aortic insufficiency ≥ 2+ at the repair’s completion. In univariate analysis, statistically significant durability differences appeared between patients with associated connective tissue disease and those with type A dissection. However, the study population includes only 32 patients with connective tissue disorders and 9 with aortic dissection, a limited sample which can not back up conclusive findings. Furthermore, no significant differences were observed in the repair rates between bicuspid and tricuspid valves.

There is also no significant difference in survival or repair durability when comparing this study sample to others using techniques that do not preserve the sinotubular junction. One advantage of aortic valve reimplantation using a larger conduit at the sinotubular junction (known as David type V, Stanford modification) is the simplified reimplantation due to added space. However, the Valsalva graft foregoes this benefit but reduces ischemic time and bleeding risk by eliminating an additional anastomosis.

In conclusion, no conclusive studies demonstrate a definitive correlation or better long-term repair durability or reduced reintervention with sinotubular junction and Valsalva sinus preservation. Current information is primarily based on imaging or flow studies via magnetic resonance. In the absence of significant outcome differences, the choice of aortic valve reimplantation technique should be based on the surgeon’s experience and comfort, as all techniques demonstrate excellent results.

REFERENCE

Chirichilli I, Scaffa R, Irace FG, Salica A, Weltert LP, D’Aleo S, et al. Twenty-year experience of aortic valve reimplantation using the Valsalva graft. Eur J Cardiothorac Surg. 2023 Mar 1;63(3). doi: 10.1093/ejcts/ezac591.

Martínez-López D, Forteza Gil A. Cirugía conservadora de la válvula aórtica en la dilatación de la raíz aórtica. Cirugía Cardiovascular. 2022 May; doi: 10.1016/j.circv.2022.03.022