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Eur J Cardiothorac Surg 2007;32:554-555. doi:10.1016/j.ejcts.2007.05.023
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved

Letters to the Editor

Reduction ascending aortoplasty: how safe is it?

Department of Cardiovascular Surgery, Bursa Yüksek Ihtisas Education and Research Hospital, Bursa, Turkey

Received 15 May 2007; accepted 31 May 2007.

^_* Corresponding author. Address: Department of Cardiovascular Surgery, Bursa Yüksek Ihtisas Education and Research Hospital, Duacinari, 16330 Bursa, Turkey. Tel.: +90 224 360 5050; fax: +90 224 360 5055. (Email: syavuz{at}ttnet.net.tr).

Key Words: Reduction ascending aortoplasty • Ascending aortic aneurysm • Aortic surgery • Bicuspid aortic valve • External reinforcement

I read with interest the article by Feindt and colleagues [1] describing a conservative operation including reduction ascending aortoplasty (RAA) with external reinforcement for ascending aortic aneurysms. I congratulate the authors on their satisfactory results.

Reduction aortoplasty with or without external reinforcement rather than graft replacement in patients with moderately sized ascending aneurysm of the aorta is still controversial. It is less technically demanding than tube graft replacement of the ascending aorta, but long-term results reveal a debatable issue.

I would like to add some comments. We do not understand why data in their article about bicuspid aortic valve (BAV) are different from the explanations in the conference discussion at end of the article. They stated in the text that they have 14 patients with BAV but that they had none in the conference discussion. Which one is true? Patients with BAV have pathology of the intrinsic aortic wall. The medial degeneration that occurs in some of these patients is likely secondary to these hemodynamic factors, although some have suggested intrinsic aortic weakness in patients with BAV [2]. This clinically reflects in the particularly frequent association of a BAV and a dilated ascending aorta. The intrinsic abnormalities of the aortic wall exclude any guarantee of satisfactory long-term results as to recurrence of the dilatation.

The other comment is about coronary bypass patients with external reinforcement. What is their way of proximal anastomosis of saphenous vein graft?

RAA with external reinforcement reduces wall stress by restoring both normal aortic diameter and wall strength [3]. On the other hand, external reinforcement has been found unnecessary in some studies. Recently, Walker and co-workers [4] have reported that, with the technique including RAA without external reinforcement, a redilatation can be prevented and the elastic property of the ascending aorta (Windkessel function) remains preserved in patients suffering from a moderately enlarged ascending aorta who require cardiac surgery for other indications. Moreover, dislocated wrap after previous RAA causes erosion of the ascending aorta. External reinforcement may cause erosion in the rear side of the aorta by the wrinkles of the prosthesis itself. To prevent late complications, especially redilatation of the ascending aorta due to dislocation of the wrap, secure anchoring of the prosthetic wrap to the aorta is mandatory [5].

In a limited group of patients suffering from concomitant aortic valve disease, we agree with the authors that RAA is an additional option but not a replacement for time-proven modern aortic surgery such as Bental's or David's procedure.

References

1. Feindt P, Litmathe J, Börgens A, Boeken U, Kurt M, Gams E. Is size-reducing ascending aortoplasty with external reinforcement an option in modern aortic surgery?. Eur J Cardiothorac Surg 2007;31:614-617.[Abstract/Free Full Text]
2. Hahn RT, Roman MJ, Mogtader AH, Devereux RB. Association of aortic dilation with regurgitant, stenotic and functionally normal bicuspid aortic valves. J Am Coll Cardiol 1992;19:283-288.[Abstract]
3. Robicsek F. Invited commentary: tailoring aortoplasty for repair of fusiform ascending aneurysms. Ann Thorac Surg 1995;59:501.[Free Full Text]
4. Walker T, Bail DHL, Gruler M, Vonthein R, Steger V, Ziemer G. Unsupported reduction ascending aortoplasty: fate of diameter and of Windkessel function. Ann Thorac Surg 2007;83:1047-1053.[Abstract/Free Full Text]
5. Bauer M, Grauhan O, Hetzer R. Dislocated wrap after previous reduction aortoplasty causes erosion of the ascending aorta. Ann Thorac Surg 2003;75:583-584.[Abstract/Free Full Text]

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				J. Litmathe and P. Feindt Reply to Yavuz Eur. J. Cardiothorac. Surg., September 1, 2007; 32(3): 555 - 555. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Senol Yavuz Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Yavuz, S. Search for Related Content PubMed PubMed Citation Articles by Yavuz, S. Related Collections Great vessels