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Eur J Cardiothorac Surg 2007;31:332-333. doi:10.1016/j.ejcts.2006.11.005
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
Letters to the Editor |
Department of Thoracic and Cardiovascular Surgery, Professor Gandjbakhch Service, University of Paris VI Pierre et Marie Curie, GH Pitié-Salpêtrière, Assistance Publique Hopitaux de Paris, 47-83, boulevard de l’Hôpital, 75651 Paris Cedex 13, France
Received 3 November 2006; accepted 6 November 2006.
* Corresponding author. Tel.: +33 1 42 16 56 43; fax: +33 1 42 16 56 39. (Email: frederique.jault{at}psl.ap-hop-paris.fr).
Key Words: Aortic dissection • Marfan syndrome
We thank Ates [1] for his remarks and interest in our work [2]. We published 12 years ago [3], a report on 339 patients who underwent surgery of the ascending aorta, including all chronic pathologies and redo patients; in our recent data [2], we focused on patients with chronic dissection of the ascending aorta who have never been operated before; the majority had severe aortic insufficiency. Clinical presentation, operative techniques and results are different according to the different pathologies, and of course are quite different in acute aortic disease, but it was not our subject.
In our report [2], the extent of the dissection is the only risk factor for operative and late mortality; 15.5% of patients had Marfan disease and 23% annulo aortic disease.
In Marfan disease, when there is no dissection, as the question raised by Ates [1], when the ascending aorta should be replaced? Aortic diameter should be measured at the sinuses of Valsalva, and related to normal values based on age and body surface area [4], especially in paediatric patients. Surgery is recommended by most surgeons when the aorta is >4.5 cm (in adults), when rapid growth of the aortic diameter occurs (>1 cm/year), when there is a family history of aortic dissection, when there is a greater than mild aortic insufficiency [5]. Some surgeons consider prophylactic aortic root replacement; this is not validated, but there is a tendency to operate at smaller diameters, when aortic insufficiency is mild or inexistent.
Composite valve graft repair is used since 1968; the long-term results are good [3]. Valve-sparing aortic root replacement is used more recently [5]. Several techniques such as Yacoub procedure (remodeling technique) and David procedure (reimplantation technique) are used.
The aortic insufficiency, when present, can be corrected, but for some surgeons, structural anomalies of valve cusps and severe aortic insufficiency are a contra-indication for these procedures. The main problem is in fact the durability of the preserved aortic valve. Fleischer had shown fragmentation and scarcity of fibrillin in the excised aortic leaflets in Marfan disease. Most of the problems emerge in the 5–10 years time; 25% of the patients at 10 years had 3+ to 4+ aortic insufficiency, especially in paediatric patients.
Patients with Marfan disease selecting a valve-sparing procedure must be warned of possible reoperation in the future.
Last, arch and descending aorta are sites for later aneurysms and dissection.
References
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