Francis Robicsek1, Joseph W Cook, Mark K Reames, Eric R Skipper. 1. Department of Thoracic and Cardiovascular Surgery and Heineman Medical Research Laboratories at Carolinas Medical Center, Charlotte, NC, USA. frobicsek@sanger-clinic.com <frobicsek@sanger-clinic.com>
Abstract
OBJECTIVE: Reduction ascending aortoplasty is a controversial procedure. Some believe that it can be appropriately applied when the anatomic features are favorable. Others suggest that it should be restricted to those patients who are at unacceptably high risk for more radical procedures, and there are also those who believe that reduction ascending aortoplasty should not be applied at all. The purpose of the article is to draw conclusions on the applicability of reduction ascending aortoplasty in modern cardiovascular surgery. METHODS: The issue was examined in the mirror of the authors' own experiences, by review and scrutiny of the literature available on the subject, and by conducting an extensive survey of the profession. RESULTS: We found that given proper indications (ie, poststenotic dilatations of <6 cm in diameter, absence of cystic medial necrosis, and a technique that decreases aortic diameter to <3.5 cm), nonreinforced reduction ascending aortoplasty performed concomitantly with aortic valve replacement appears to be a simple and safe procedure, with low morbidity and mortality and rare late complications. External reinforcement might extend the scope of indication for reduction ascending aortoplasty to ascending aortic aneurysms associated with aortic regurgitation and to those with primary structural aortic wall disease with comparable results. Experience also has shown that late complications might be further reduced by means of proper proximal anchoring and extending the wrap past the origin of the innominate artery. CONCLUSIONS: We conclude that reduction ascending aortoplasty is certainly alive. Although it does not appear to be an extremely popular operation, about half of the surgeons who responded believe it to be justified. Regardless of which modality is used, lifetime monitoring of ascending aortic size is essential and so advised. Because of recent sporadic reports of "under-the-wrap" aortic wall atrophy and rupture, the issue of reinforcement of reduction ascending aortoplasty requires continued re-evaluation.
OBJECTIVE: Reduction ascending aortoplasty is a controversial procedure. Some believe that it can be appropriately applied when the anatomic features are favorable. Others suggest that it should be restricted to those patients who are at unacceptably high risk for more radical procedures, and there are also those who believe that reduction ascending aortoplasty should not be applied at all. The purpose of the article is to draw conclusions on the applicability of reduction ascending aortoplasty in modern cardiovascular surgery. METHODS: The issue was examined in the mirror of the authors' own experiences, by review and scrutiny of the literature available on the subject, and by conducting an extensive survey of the profession. RESULTS: We found that given proper indications (ie, poststenotic dilatations of <6 cm in diameter, absence of cystic medial necrosis, and a technique that decreases aortic diameter to <3.5 cm), nonreinforced reduction ascending aortoplasty performed concomitantly with aortic valve replacement appears to be a simple and safe procedure, with low morbidity and mortality and rare late complications. External reinforcement might extend the scope of indication for reduction ascending aortoplasty to ascending aortic aneurysms associated with aortic regurgitation and to those with primary structural aortic wall disease with comparable results. Experience also has shown that late complications might be further reduced by means of proper proximal anchoring and extending the wrap past the origin of the innominate artery. CONCLUSIONS: We conclude that reduction ascending aortoplasty is certainly alive. Although it does not appear to be an extremely popular operation, about half of the surgeons who responded believe it to be justified. Regardless of which modality is used, lifetime monitoring of ascending aortic size is essential and so advised. Because of recent sporadic reports of "under-the-wrap" aortic wall atrophy and rupture, the issue of reinforcement of reduction ascending aortoplasty requires continued re-evaluation.