Anatomy:

The aortic root is the first portion of the aorta and is comprised of:

  • aortic valve

  • annulus

  • aortic sinuses

  • coronary ostium

Associate Conditions:

  • Marfan syndrome

  • Inflammatory/autoimmune diseases

  • Loey-Dietz Syndrome

  • Bicuspid aortic valve

  • Annulo-ectasia

 

The aortic root aneurysms associated with Marfan syndrome have a “pear-like” appearance with quite normal aortic diameter measurements up until the aortic arch

Treatment:

 

The general consensus is to operate when:

  • aortic root has reached 5.5 cm in good surgical candidates  

  • degree of aortic valve regurgitation, symptoms, the size of the left ventricle (the result of overload on the left ventricle from the aortic regurgitation) all need to be considered when making the decision to proceed with elective repair  

  • rate of growth of the aortic root must also be considered.  When an aortic root aneurysm expands by more than 0.5 cm in one year, one may consider to elective repair regardless if the diameter is less than 5.5 cm  

  • degree of aortic valve regurgitation and the size of the left ventricle may influence earlier surgical intervention

 

Patients with connective tissue disorders such as Marfan and Loey-Dietz Syndromes are offered elective aortic root replacement at smaller aortic diameters.  Patents with Loey-Dietz syndrome have a very aggressive aortic condition resulting in acute aortic dissections at very small aortic diameters. In theses patients, surgical repair is recommended at aortic diameter of 4.5 cm.   In Marfan syndrome, the recommended aortic diameter is 5.0 cm, although, if there is a strong family history of aortic dissection, earlier repair should be offered.  In patients with Turner’s Syndrome, it seems reasonable to offer surgical repair at a aortic diameter of 4.5 cm or aortic index of >2.5 cm/mm2.

 

  • Bentall is the gold standard  (ascending aorta, aortic valve replaced, and coronaries re-implanted)

  • Aortic-Valve sparing root replacement (Yacoub and David procedure):

    • connective tissue disorder

    • young patients

    • can’t take anticoagulation

    • personal preference

 

Re-implantation of coronaries

Composite graft: a graft composed of two or more tissue types, such as skin and cartilage or skin and subcutaneous fat

... but I would more especially commend the clinician who, in acute diseases, by which the bulk of mankind are cutoff, conducts the treatment better than others.
 
Hippocrates, 400 BC