Considering valve competence
Using a supracoronary interposition graft and resuspension of the native
aortic valve, has numerous potential advantages over aortic valve
replacement. The approach is technically more straightforward than root
replacement, the latter requiring more operative steps and technical
skill, especially in the emergency setting. Additionally, in young
patients who are otherwise likely to receive a mechanical valve
replacement, native valve preservation avoids the risks of long term
anticoagulation, including delayed false lumen thrombosis and
haemorrhagic events. Keeping the native aortic valve also leaves many
options open for reintervention decades down the line should the younger
patient require it. In older patients, especially when the native
leaflets exhibit normal morphology, avoiding bioprosthetic valve
replacement may defer complications associated with structural valve
degeneration [4].
Studies have supported the choice of supracoronary interposition
grafting in ATAAD in patients without a definitive indication for aortic
valve replacement. The present study goes further: even with severe AR
at the time of emergency surgery, valve resuspension can yield good
long-term results and severe AR should not be a considered a
contraindication for AAG. Few studies have examined the performance of
the native aortic valve following type A aortic dissection and in these
there is a lack of consensus regarding the significance of aortic
regurgitation at presentation. Molteni et al. and Tang et
al. found that aortic regurgitation at presentation was not a predictor
of subsequent reintervention of the aortic valve or aortic regurgitation
in a retrospective case series [14][15]. In contrast Pesottoet al. did find that moderate or severe aortic regurgitation at
presentation was associated with an increased risk of moderate or severe
aortic regurgitation during follow-up in patients undergoing aortic
valve resuspension [16].
The long-term durability of the native aortic valve and root was found
to be good in this case series. In total six patients in this series
required reintervention on the native aortic root or valve. A modest
deterioration in the function of the native aortic valve was observed
with 9 and 3 patients developing moderate and severe aortic
regurgitation respectively following discharge.