**4. Aortic root aneurysm**

The American Association of Thoracic Surgeons present following guidelines regarding surgery for the ascending aorta [27]:


phenotype bicuspid aortic valve, uncontrolled hypertension, history of aortic dissection or sudden death in the family, annual enlargement of 3 mm or more in the size of the aortic aneurysm, or predominantly aortic regurgitation.


Patients with Marfan's syndrome or Marfanoid habitus should be operated when their aortic root/ascending aorta is larger than 50 mm in maximal transverse diameter [28]. Gott and colleagues [27, 28] reported an improved 30-day survival in a series of 675 patients with Marfan's syndrome who underwent elective compared to urgent or emergency replacement of the aortic root.

If patients have a family history of aortic dissection, demonstrate an annual increase of 3 mm or have significant aortic regurgitation, then aortic root surgery is warranted when diameters exceed 45 mm [29]. Hormonal changes during pregnancy significantly increase risk of aortic dissection. Hence, women of child-bearing age who are keen to have a family are recommended surgery prior to pregnancy. These guidelines are also applicable to patients with Ehlers-Danlos syndrome and Loeys-Dietz syndrome.

#### **5. Sinus of Valsalva aneurysm**

Sinus of Valsalva aneurysms are rare; reported in 0.09% of autopsy series [30]. This condition affects commonly the right coronary sinus to a lesser degree the noncoronary sinus; involvement of all three sinuses is reported but exceedingly uncommon [31]. While idiopathic in majority, endocarditis is a rare cause [32]. Surgery is indicated to prevent rupture [32]. Rupture is often into an adjacent heart chamber with high-out heat failure [33]. Surgery consists of patch closure of the involved sinus. Approach can be from the aorta as well as via the other heart chamber that the fistula opens [30].

#### **6. Aortic dissection**

Acute aortic dissection is a high-risk aortic catastrophe which occurs in 5–30/1,000,000 patient annually [37]. Almost 1/5th die before reaching the emergency [38]. The initiating factor is often uncontrolled hypertension. Patients may have an intra-mural hematoma prior to developing dissection.

Aortic dissection is classified according to the time after the start of symptoms, being acute if the time frame between the onset of symptoms and presentation is less than 14 days, and chronic if this period is more than 14 days [34]. Anatomical classification is based on the location and extension of the primary tear (**Figure 2**). Dr. DeBakey and colleagues [35] described a method of classification that differentiates the aortic segments involved into: Type I, when the dissections is involving all the aortic segments, while Type II, when the dissection is confined to the ascending aorta, while Type III, when the dissection process is affecting the descending

**39**

not [37].

**Figure 2.**

aortic dissection [38].

*the aortic segment involved are illustrated [36].*

**7. Bentall procedure**

Nicholas Kouchoukas [14].

high volume [40].

*Aortic Root Reconstruction*

*DOI: http://dx.doi.org/10.5772/intechopen.86034*

thoracic aorta. A more functional classification was introduced by the Stanford University; type A if the dissection involves the ascending aorta, type B if it does

*The anatomical classification of aortic dissection according to the location of the primary tear and the extent of* 

The devastating complications that may occur with aortic dissection including organ malperfusion syndromes, acute aortic regurgitation, pericardial tamponade and stroke [38]. Surgery is currently the gold standard for acute care of type A

Bentall and de Bono described their technique of aortic root replacement with a synthetic tube graft and contained prosthetic valve [39]. The coronary ostia were implanted in an end to side fashion without coronary mobilization [39]. Bleeding and pseudo-aneurysms were important complications with their procedure [40]. The present method of coronary mobilization and anastomosis was introduced by

Use of improved graft substitutes and local hemostatic agents have made this procedure safer [41]. Results are good in centers performing these procedures in

The Bentall procedure in younger patients is often performed with a mechanical valve conduit. Appropriate anti-coagulation is important to maintain event-free survival [42]. A recent meta-analysis of 7600 [42] patients who had a mechanical valve conduit reported reoperation rates of Bentall procedure using mechanical valve conduits that the annual linearized rate of occurrence of aortic root re-operation 0.45% (0.039–0.59%). Late mortality was 2.02% (1.77–2.31%) and for hemorrhage

However, in older patients, or those who refuse/have contraindications for anticoagulation, a biologic valve substitute can be used [43]. Gaudino and colleagues

was 0.64% (0.47–0.87%) During a mean follow up of 6 years.

*Aortic Root Reconstruction DOI: http://dx.doi.org/10.5772/intechopen.86034*

#### **Figure 2.**

*Cardiac Surgery Procedures*

outcomes

surgery.

Loeys-Dietz syndrome.

the fistula opens [30].

**6. Aortic dissection**

**5. Sinus of Valsalva aneurysm**

phenotype bicuspid aortic valve, uncontrolled hypertension, history of aortic dissection or sudden death in the family, annual enlargement of 3 mm or more in the size of the aortic aneurysm, or predominantly aortic regurgitation.

c.Surgical repair should be performed when aortic diameter (root or ascending aorta) is 50 mm or more in patients with low operative risk being performed by experienced aortic surgical team in centers with well-established surgical

d.Surgical repair should be performed when aortic diameter (root or ascending aorta) is 45 mm or more in patients undergoing concomitant other cardiac

Patients with Marfan's syndrome or Marfanoid habitus should be operated when their aortic root/ascending aorta is larger than 50 mm in maximal transverse diameter [28]. Gott and colleagues [27, 28] reported an improved 30-day survival in a series of 675 patients with Marfan's syndrome who underwent elective compared

If patients have a family history of aortic dissection, demonstrate an annual increase of 3 mm or have significant aortic regurgitation, then aortic root surgery is warranted when diameters exceed 45 mm [29]. Hormonal changes during pregnancy significantly increase risk of aortic dissection. Hence, women of child-bearing age who are keen to have a family are recommended surgery prior to pregnancy. These guidelines are also applicable to patients with Ehlers-Danlos syndrome and

Sinus of Valsalva aneurysms are rare; reported in 0.09% of autopsy series [30]. This condition affects commonly the right coronary sinus to a lesser degree the noncoronary sinus; involvement of all three sinuses is reported but exceedingly uncommon [31]. While idiopathic in majority, endocarditis is a rare cause [32]. Surgery is indicated to prevent rupture [32]. Rupture is often into an adjacent heart chamber with high-out heat failure [33]. Surgery consists of patch closure of the involved sinus. Approach can be from the aorta as well as via the other heart chamber that

Acute aortic dissection is a high-risk aortic catastrophe which occurs in 5–30/1,000,000 patient annually [37]. Almost 1/5th die before reaching the emergency [38]. The initiating factor is often uncontrolled hypertension. Patients may

Aortic dissection is classified according to the time after the start of symptoms, being acute if the time frame between the onset of symptoms and presentation is less than 14 days, and chronic if this period is more than 14 days [34]. Anatomical classification is based on the location and extension of the primary tear (**Figure 2**). Dr. DeBakey and colleagues [35] described a method of classification that differentiates the aortic segments involved into: Type I, when the dissections is involving all the aortic segments, while Type II, when the dissection is confined to the ascending aorta, while Type III, when the dissection process is affecting the descending

have an intra-mural hematoma prior to developing dissection.

to urgent or emergency replacement of the aortic root.

**38**

*The anatomical classification of aortic dissection according to the location of the primary tear and the extent of the aortic segment involved are illustrated [36].*

thoracic aorta. A more functional classification was introduced by the Stanford University; type A if the dissection involves the ascending aorta, type B if it does not [37].

The devastating complications that may occur with aortic dissection including organ malperfusion syndromes, acute aortic regurgitation, pericardial tamponade and stroke [38]. Surgery is currently the gold standard for acute care of type A aortic dissection [38].

#### **7. Bentall procedure**

Bentall and de Bono described their technique of aortic root replacement with a synthetic tube graft and contained prosthetic valve [39]. The coronary ostia were implanted in an end to side fashion without coronary mobilization [39]. Bleeding and pseudo-aneurysms were important complications with their procedure [40]. The present method of coronary mobilization and anastomosis was introduced by Nicholas Kouchoukas [14].

Use of improved graft substitutes and local hemostatic agents have made this procedure safer [41]. Results are good in centers performing these procedures in high volume [40].

The Bentall procedure in younger patients is often performed with a mechanical valve conduit. Appropriate anti-coagulation is important to maintain event-free survival [42]. A recent meta-analysis of 7600 [42] patients who had a mechanical valve conduit reported reoperation rates of Bentall procedure using mechanical valve conduits that the annual linearized rate of occurrence of aortic root re-operation 0.45% (0.039–0.59%). Late mortality was 2.02% (1.77–2.31%) and for hemorrhage was 0.64% (0.47–0.87%) During a mean follow up of 6 years.

However, in older patients, or those who refuse/have contraindications for anticoagulation, a biologic valve substitute can be used [43]. Gaudino and colleagues

demonstrated in a propensity matched cohorts that included patients who underwent aortic root replacement utilizing mechanical valved conduit versus biological valved conduit versus valve sparing procedure that the type of procedure did not influence early or late outcome, however rate of aortic re-operation was 0, 2.4, 7.3% at 5 years for mechanical, biological valved conduits and valve sparing procedure, respectively [43].
