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J Thorac Cardiovasc Surg 2007;134:824
© 2007 The American Association for Thoracic Surgery

Letter to the Editor

Reply to the Editor

University of J.W. Goethe, Frankfurt am Main, Germany

We thank Dr Robicsek for his comment on our article "Six Stitches to Create a Neosinus in David-type Aortic Root Resuspension." He has extensive experience in this field. We agree that a rigid tube will never achieve the same compliance as the native aortic root, and that this increases the stresses on the leaflets. However, the question is still to be answered if this has clinical impact, especially whether the higher leaflet stresses have more impact on long-term durability than an optimal geometric reconstruction. Because the aortic sinuses and leaflets dilate, stretch, and reshape to an individual configuration in many patients, each leaflet and sinus has to be recreated to achieve an optimal coaptation. Clinical reports do not show perfect or suboptimal long-term results for the remodeling operation.¹ In David and colleagues’ personal comparison,¹ reimplantation had significantly better long-term results than remodeling.² In our opinion, this is because it is easy to overcorrect the aortic valve in the David procedure, avoiding any sagging and stabilizing the slightly dilated annulus. We fully agree that the onion shape is a suboptimal solution because it does not support the naturally straight course of the commissures. This is optimized by the technique described in our article.

It still has to be proven that the optimal leaflet stress reduction is achieved in the manner suggested by Dr Robicsek, that is, the sinotubular junction is kept rigid by the Dacron tube and the elasticity of the remaining aortic root is preserved. The latter will be reduced by the scarring process in the long term.

Individual matching between sinuses and leaflet is easily accomplished with our technique because the reduction at the sinotubular junction is only done with the valve already inside the tube and thus can be easily positioned at the optimal spot. Because the total load on the leaflets is determined by the product of area, time’s pressure overcorrection reduces the mechanical stress on the usually enlarged leaflets. There is currently no proof that optimizing root remodeling with respect to compliance and thus possibly reduced leaflet stresses achieves better long-term results than does an optimal straightforward geometric repair with slight overcorrection.

We thank Dr Robicsek for his important thoughts.

References

1. David TE, Feindel CM, Webb G, Colman J, Armstrong S, Maganti M. Long-term results of aortic valve-sparing operations for aortic root aneurysm. J Thorac Cardiovasc Surg. 2006;132:347-354.[Abstract/Free Full Text]
   
2. Yacoub M, Gehle P, Chandrasekaran V, Birks E, Child A, Radley-Smith R. Late results of a valve-preserving operation in patients with aneurysms of the ascendens aorta and root. J Thorac Cardiovasc Surg. 1998;115:1080-1090.[Abstract/Free Full Text]
   

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Anton Moritz Tayfun Aybek Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Moritz, A. Articles by Aybek, T. Search for Related Content PubMed Articles by Moritz, A. Articles by Aybek, T. Related Collections Related Article