What Is The Aortic Root? - Division of Cardiac Surgery

Mohammad Shihata
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
The Aortic Root Consists of :

Aortic annulus

Aortic cusps

Aortic Sinuses

Sinotubular Junction (STJ)
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.
Too large ( Root Aneurysm )
Too small ( small annulus )

-

-

-
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
Root Abscess ( Endocarditis )

Replacement
- Bentall
- Mechanical
- Stented tissue
- Stentless tissue
+/Mitral / LA
Reconstruction
Type A Dissection
Bentall
- Mechanical
- Stented tissue
- Stentless tissue
 Valve Sparing
- Remodelling
- Reimplantation

 Degenerative
 Connective
 Bicuspid
 Post
Tissue Disorders
Aortopathy
Stenotic
 Chronic
Dissections
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
Reimplantation ( David I)
Remodelling ( Yacoub)
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.
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.
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.
In 1992, David and Feindel published a series of 10 patients
167 patients , 10 year follow up
 Survival (92%)
 Freedom from moderate to severe AI (94%)
 Freedom from Aortic reoperation (95%)
325 (David I), 59 Marfans
 80%
freedom from reoperation at 10y
 8.5%
late mortality
•
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

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
0.2% Preserved in
glutaraldehyde
•
•Polyester
cuff
sewing
•Alfa
amino oleic acid
( anticalcification )
•Zero
net pressure
fixation of the leaflets




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
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. 2007 Nov;16(6):649-55;]
725 patients, 92.4% freedom from SVD at
12 years
 57
Reoperations in 12 y ( 1993 - 2005)
 10
Freestyles, 2 SVD (7 & 9 years) & 8
Endocarditis
 Reop
within 1 y was an independant risk factor
for mortality
Sizes 21 mm - 27mm
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
 No
Anticoagulation/ Thromboembolic
complications
 Potential
for Growth
 Improved
hemodynamics
 Reduced
risk of Endocarditis
 Scalloped
 Inclusion
( Subcoronary )
Cylinder
 Freestanding
 Supported
Root
Root
Subcoronary
Inclusion Cylinder
 Two
centres, 347 patients, 1994 – 2005
( Subcoronary )
 0.6% hospital mortality
 FU 3.9 +/- 2.7 years
 95% freedom from all cause reoperation
 487
patients
 80% freedom from Aortic reoperation
 84% freedom from Allograft reoperation
 95% freedom from endocarditis
 1 TEC