Ascending aortic aneurysm and aortic valve disease: what is the most optimal surgical technique?

The merits of separate versus composite valve graft replacement for the treatment of patients with ascending aortic aneurysms or dissections associated with aortic valve disease remain a controversial issue. Considering all available clinical data, the early and late results surprisingly are quite similar between the two procedures. However, patient selection criteria and operative technique are important. In patients with the Marfan syndrome and in those with significantly diseased or destroyed sinuses, composite valve graft replacement is the procedure of choice. The "open" (Carrel button) method of coronary reimplantation is recommended in almost all cases to minimize the risk of late false aneurysm formation. If the aortic leaflets are normal, a valve-sparing aortic root remodeling procedure is a reasonable alternative in certain individuals. Separate valve graft replacement is still a satisfactory option in other (non-Marfan) patients; however, most of the sinuses should be resected, leaving only small tongues of aortic wall surrounding the coronary ostia to reduce the risk of late aortic root aneurysmal degeneration. In patients with complex prosthetic valve endocarditis or multiple paravalvular leaks, homograft aortic root replacement is a good option after radical debridement of all infected or devitalized tissue.