**9. References**


valves. Those with functionally bicuspid (Type 1) valves, raphe repair was accomplished by either shaving, resection or use of a pericardial patch. At 5 years, freedom from recurrent regurgitation was high at 94±3%. Furthermore, in unadjusted analyses, patients undergoing a root procedure (remodelling or reimplantation) had a greater freedom from recurrent regurgitation compared to those undergoing subcommissural annuloplasty or sinotubular

De Paulis and colleagues showed that early valve motion after re-implantation inside the Valsalva prosthesis was similar to those of normal subjects, with graft distensibility being retained at the neosinuses [26]. At late follow-up, the elasticity of the graft's sinuses were also to an extent maintained, with the graft reponding to the changes in pressure between systole and diastole [27]. Further studies may elucidate any haemodynamic or clinical differences between techniques used to create neosinuses. Implantation of the Valsalva prosthesis removes the need to fashion neosinuses from a tube graft, which may prove advantageous by reducing aortic cross clamp times in cases where the aortic pathology

Evidence thus far shows that preservation and repair of the native aortic valve can be achieved with promising mid-term outcomes. It is rapidly becoming an accepted part of routine clinical practice. We believe that further studies with long-term follow up will reveal

[1] Swanson M, Clark RE. Dimensions and geometric relationships of the human aortic

[2] Silver MA, Roberts WC. Detailed anatomy of the normally functioning aortic valve in hearts of normal and increased weight. Am J Cardiol 1985;55:454-461. [3] Kunzelman KS, Grande KJ, David TE, Cochran RP, Verrier ED. Aortic root and valve

[4] Katayama S, Umetani N, Sugiura S, Hisada T. The sinus of valsalva relieves abnormal

[5] Bellhouse BJ Bellhouse FH. Mechanism of closure of the aortic valve. Nature 1968;217:86-

[6] Robicsek F, Thubrikar MJ. Role of sinus wall compliance in aortic leaflet function. Am J

relationships. Impact on surgical repair. J Thorac Cardiovasc Surg 1994;107:162-170.

stress on aortic valve leaflets by facilitating smooth closure. J Thorac Cardiovasc

the greater potential of valve-sparing aortic root replacement and aortic valve repair.

The authors wish to acknowledge Ms Beth Croce for her illustrative work.

Professor Matalanis, Dr . Shi and Dr. O'Keefe report no conflicts of interest.

valve as a function of pressure. Circ Res 1974;35:871-882.

junction plication (95± 5%vs 80±6% at 5 years, p=0.03) [25].

extends into the aortic arch requiring complex reconstruction.

**5.3 Impact of the vascular prosthesis** 

**6. Conclusions** 

**8. Disclosures** 

**9. References** 

87.

**7. Acknowledgements** 

Surg 2008 136:1528-1535.

Cardiol 1999;84:944-946.


**1. Introduction** 

**2. Anatomy** 

subcommissural triangle.

**6** 

*USA* 

**Aortic Valve** 

**Sparing Operations** 

*Division of Cardiothoracic Surgery, Emory University School of Medicine* 

Bradley G. Leshnower and Edward P. Chen

The treatment of aortic root and ascending aortic aneurysms often requires addressing concomitant aortic valve pathology. In the setting of aortic stenosis secondary to cusp degeneration, aortic valve replacement (AVR) is performed. However, when patients present with aortic insufficiency and normal cusp anatomy, a dilemma arises. Historically valve replacement has been performed; however, current options are all associated with their own specific issues. Implantation of a mechanical prosthesis commits the patient to lifelong anticoagulation and the concomitant risks of bleeding and thromboembolism. Use of a bioprosthetic valve eliminates the burden of anticoagulation, but these prostheses suffer from structural valve deterioration and commit the young patient to the potential need for a second or third operation. The optimal solution is to remove all diseased aorta while preserving and restoring the normal aortic cusps to their original geometry to allow for adequate coaptation and valve competency. The term "aortic valve-sparing operations" (AVS) was introduced by David in the 1990's to describe procedures which preserved, rather than replaced the aortic valve cusps during the treatment of aneurysms of the aortic root or ascending aorta with associated aortic insufficiency (1). These are technically demanding procedures which require in-depth knowledge and comprehension of aortic root anatomy and physiology. In this chapter we will review the anatomy and physiology of the aortic root and discuss the various AVS operations which have been used in the

The aortic root is a complex structure composed of several components including the aortic annulus, valve cusps, sinus of Valsalva segments, and the sinotubular junction. The aortic annulus is defined by the attachment or hinge point of the cusp and has been described as scalloped or coronet shaped. It is attached to ventricular myocardium in 45% of its circumference and fibrous structures in the remaining 55%. The annulus rises from the nadir of one cusp and peaks at the commissure, the highest point of the annulus and the junction between two adjacent cusps. The area below the commissures is referred to as the

treatment of aortic root and ascending aortic aneurysms.

