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Eur J Cardiothorac Surg 2007;32:555. doi:10.1016/j.ejcts.2007.05.022
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, Heinrich-Heine-University, Duesseldorf, Germany
Received 30 May 2007; accepted 31 May 2007.
* Corresponding author. Address: Department of Thoracic and Cardiovascular Surgery, Heinrich-Heine-University, Moorenstrasse 5, D-40225 Duesseldorf, Germany. Tel.: +49 211 8118331; fax: +49 211 811833. (Email: litmathe{at}med.uni-duesseldorf.de).
Key Words: Aortic surgery • External reinforcement • Ectasia • Bicuspid valve
We thank Dr Yavuz sincerely for his comments and the interest to share his own experience on this topic [1].
The first point is, unfortunately, based on a misunderstanding during the discussion at the conference in Stockholm. Feindt misunderstood the question regarding how many bicuspid valves were reconstructed in our cohort and thought that the answer was none [2]. The actual number of patients with natively bicuspid aortic valves (BAV) is 14 as shown in the paper and also demonstrated during the lecture.
Yavuz then states that BAV contains intrinsic abnormalities of the aortic wall and reduction aortoplasty might not represent the therapy of choice for those patients. Therefore, it has to be mentioned that the decision for either replacement of the ascending aorta with or without the aortic valve (e.g. for a Bentall procedure on the one hand or for reduction aortoplasty on the other) is based firstly on patient's history (i.e. known familiar anamnesis for medianecrosis) and secondarily on the diameter and the pathologic form of the ectasia. In no case were the histopathologic changes of an individual patient notable prior to or during the operation. Furthermore, it is well known that bicuspid valves and also tricuspid valves may reveal medianecrosis of the ascending aorta.
The next question to answer was in relation to where the proximal anastomoses have been made: Due to the external reinforcement, they were performed in the area of the proximal aortic arch.
Walker and colleagues [3] have reported that external reinforcement may be unnecessary and impair the elastic property of the ascending aorta; additionally, the prosthesis could dislocate and induce erosions on the aortic wall. We agree with other authors [4,5] and think that reinforcement is mandatory due to redilation independent from the underlying disease. The correct technique, however, is binding, i.e. anchoring of the prosthesis with the aortic wall. In such cases, dislocation and erosion forces can be minimized.
We especially feel that Yavuz's final statement that reduction aortoplasty is not a replacement for modern aortic surgery should be weighed critically: in the case of known medianecrosis, complete replacement of the ascending aorta with or without reconstruction (David)/replacement (Bentall) is obligatory, but nevertheless on the base of form (typical poststenotic), diameter (below 50 mm) and anamnesis (no familiar history for medianecrosis) of an individual patient, we think that reduction aortoplasty with external reinforcement represents a real alternative in aortic surgery.
References
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