The document discusses different techniques for aortic valve-sparing operations, including the remodeling technique developed by Yacoub and the reimplantation technique developed by David. It describes the technical steps for each procedure and compares their early mortality rates and long-term outcomes. While both techniques can successfully preserve native valve function, the reimplantation technique may be preferable to remodeling for certain patient anatomies or pathologies like bicuspid valves, Marfan syndrome, or acute aortic dissection. Intraoperative imaging is important for assessing valve competence after repair.

1. Aortic valve-sparing
operations
Dicky A.Wartono,MD
Aortic Surgery

2. • Conventional treatment of patients with aortic
root pathology—using a composite tube graft
• lifelong anticoagulation,
• risk of thromboembolismand bleeding,
• effects of cerebral microemboli,
• thecontinuous burden to the left ventricle owing to
increasingaortic outflow resistance.
• the psychologic drawback of heart valve noise,
Interactive CardioVascular and Thoracic
Surgery 13 (2011) 189-197
J Thorac Cardiovasc Surg 2008;116:990-996

3. • Option for children and young adults with aortic
sinus +/- ascending aneurysm

• preserve N restore valve competence
• Avoids problems of valve prostheses
Valve Sparing Root Replacement
Valve Sparing Aortic Root Replacement: Technical Tips and Pitfalls
Duke E. Cameron, MD
Division of Cardiac Surgery The Johns Hopkins Hospital Baltimore, Maryland
Adult Cardiac Skills Course AATS 2012

4. valve-preserving techniques :
•remodelingtechnique (by Yacoub and
colleagues)
•reimplantation technique (David and Feindel)

5. Dacron graft is anchored to the
aortoventricular junction. The native aortic
valve is then resuspended within the vascular
graft.
Dacron graft is tailored to conform
the shape of the 3 aortic sinuses
and then anastomosed to the aortic
root.

6. Valve sparing aortic replacement – root
remodeling
Operative Techniques in Thoracic and Cardiovascular Surgery
2005;10(4):246–258

7. The diseased aortic sinuses are excised down
to the aortic annulus, which is always healthy
and can hold sutures securely even in patients
with acute dissection.
choosing an appropriately sized Dacron tube,
passing horizontal mattress sutures just above
the top of each commissure and stretching the
three commissures in a vertical direction while
observing the position of the cusps.

8. choosing graft size and take a graft of
approximately 1 to 2 mm smaller than the
diameter of the aorto-ventricular junction.
Three longitudinal cuts are
made in one of the ends of the
graft. The length of these
longitudinal cuts should be
approximately three fourths
of the diameter of the graft.
The ends are rounded (B)

9. suture are passed from the
inside to the outside of the
graft immediately ahovr the
end of the longitudinal cuts,
and then from the inside to
the outside of the rtminants
of the aortic.
The Dacron graft is then
sutured to the remnants of
the aortic sinuses along the
aortic annulus. It is safer to
start at the commissural level
and to sew toward the central
portion of the sinus to
prevent maldistrihution of the
tailored graft along the aortic.
annulus.
The graft should lie inside the
remnants of the aortic
sinuses.

10. aortic valve is tested for incompetence
If the. leaflets do not touch each other in the center, the graft may be too
large; this can he corrected by sewing the diameter of the sinotubular
junction.
If the leaflets coapt excessively, thev may prolapse under pressure.
the best method is by Doppler echocardiography after discontinuation of
cardiopulmonary bypass.

11. The right and left coronary arteries are then
reimplanted into their respective sinuses by
making an opening in the graft and suturing
the remnants of the sinus wall around each
cornnary artery.

13. Valve-sparing aortic root replacement: the
inclusion (David) technique
Operative Techniques in Thoracic and Cardiovascular Surgery 2005;10(4):246–258
David TE, Feindel CM: An aortic valve-sparing operati(in for patients with aortic incompetence
and aneurysm of the asrending aorta. J Thorac Cardiovasc Surg 103:617-622, 1992

14. For the correct sizing of the appropriate Dacron graft, commissures must be pulled up to
create a virtual cylinder with cusp coaptation of 30–50%.

15. Horizontal mattress sutures without pledges
are placed in one lane underneath the sinuses
for later fixation of the graft to the aortic root.
When knots of the horizontal
mattress are gently tied, the
graft must be pushed down and
held in position by the assistant.
A pivotal step of the
reimplantation procedure
is the posi- tioning of the
commissures high enough
into the Dacron tube by
pulling on the stay
sutures, reshaping a
correct geometry of the
valve.

16. Valve implantation:
slightly pulling on both the commissure and the
vascular graft before stitching the sutures through
the graft.
the graft should extend roughly by half of its
maximum length at this segment.
Insertion of saline allows a first judgment of
leakproofness of the valve.
After completion of the reimplantation,
the valve must appear in means of the
geometry like a ‘Mercedes star’, but indi-
vidual differences in length of cusps are
possible.

17. Completion of the procedure: Coronary ostia
are reim- planted into the Dacron prosthesis
by use of 5-0 monofilament run ning suture
The reimplantation of partially resected
sinuses of valsalvae starts at the Nadir of the
three coronary sinuses, each with double
armed monofila- ment sutures going up to
both commissures, where sutures were tied to
each other. This suture line must be
hemostatic! Stay sutures are tied and cut too.

18. Relationship between height of resuspension
of the reimplanted valve and occurrence of
postoperative aortic insufficiency.

19. Intraoperative transesophageal
echocardiographic criteria to appreciate
quality of the result after valve repair

20. - Optimal STJ diameter (+3-4mm)
- Free leaflet length (+3-4mm)=graft diameter
- Height of L-NC commissure
- BSA
-aortic annulus should not exceed
- the length of the free margin of the leaflets
- twice the height of the leaflets
• If in doubt, go with larger graft
• If in severe doubt, use a 30mm graft
•Never apologize for a Bentall

Selection of Graft Size
Valve Sparing Aortic Root Replacement: Technical Tips and Pitfalls
Duke E. Cameron, MD
Division of Cardiac Surgery The Johns Hopkins Hospital Baltimore,

21. Valve Sparing Aortic Root Replacement: Technical Tips and Pitfalls
Duke E. Cameron, MD
Division of Cardiac Surgery The Johns Hopkins Hospital Baltimore,
Maryland
Adult Cardiac Skills Course AATS 2012

22. Repair of prolapsing aortic leaflet with 6-0
Gore-Tex suture.

23. Diagram of aortic valve lesions and
corresponding re- pair teechniques.
Aortic. regurgitation with
decreased cusp moobilitydity.
Iliagram of aortic. valve lesions and
correcspondingrt.pair techniques. Aortic
reguritation with increased cusp mobility
Diagram of aortic. valve lesions and
rorrrsponding repair technic1ue.s. Aortic re-
gurgitation with normal cusp mobility.

24. Most important features of valve-preserving root
replacement

25. In 2003, Miller introduced a classification to the Tirone David's
• David-I is the original reimplantation procedure using a cylindrical tube
graft,
•David-II is the original Yacoub remodeling procedure,
•David-III is the remodeling procedure with an external narrowing
annuloplasty strip,
•David-IV is reimplantation using a 4-mm larger graft size with plication of
the graft circumferentially at the sinotubular junction (STJ) above the tops of
the commissures, and
•David-V is reimplantation using an even larger graft size, which is ‘necked
down’ at both the bottom and the top ends to create graft pseudosinuses
Miller DC
. Valve-sparing aortic root replacement in patients with the Marfan syndrome. J Thorac Cardiovasc Surg
2003;125:773-778

26. • whether the reimplantation (David) technique or the
remodeling (Yacoub) technique provides the optimum
event free survival
• 14 papers provided the best evidence
• total of 1338 patients (Yacoub technique in 606 and
David technique in 732)
• 13 centres were includedInteractive CardioVascular and Thoracic
Surgery 13 (2011) 189-197
J Thorac Cardiovasc Surg 2008;116:990-996

27. • Early mortality ranged from
– 0% to 6.9% for the Yacoub technique and
– 0–6% for the David technique.
• In the largest available series reported by David et al.
in 2010
– 1.6% in the Yacoub group and
– 1.7% in the David group.
• acute type A dissection ,the overall early mortality
was 17%
AATS meting 2012. ctsnet.org2012
Interactive CardioVascular and Thoracic
Surgery 13 (2011)
jtcs.ctsnetjournals.org tcvs.2008
J Thorac Cardiovasc Surg 2008;116:990-996
Circulation. 2002;106[suppl I]:I-229-I-233

28. Clinical bottom line
• The results for both techniques were almost comparable.
• Bicuspid
• favour of the David technique rather than the Yacoub
technique in pathologies such as
• Marfan syndrome,
• acute type A aortic dissection
• excessive annular dilatation
AATS meting 2012. ctsnet.org2012
Interactive CardioVascular and Thoracic
Surgery 13 (2011)
jtcs.ctsnetjournals.org tcvs.2008
J Thorac Cardiovasc Surg 2008;116:990-996
Circulation. 2002;106[suppl I]:I-229-I-233

29. • less freedom from AR in the Yacoub than the David
• not been associated with thromboemboliccomplications, the
riskof valve endocarditis
• Predictor of (early) failure
– Patient selection
– Cusp repair
– Coronary reimplantation AATS meting 2012. ctsnet.org2012
Interactive CardioVascular and Thoracic Surgery 13 (2011)
jtcs.ctsnetjournals.org tcvs.2008
J Thorac Cardiovasc Surg 2008;116:990-996
Circulation. 2002;106[suppl I]:I-229-I-233
.

30. Left to right: remodeling, modified
remodeling, sinus prosthesis, modified sinus
prosthesis, reimplantation, and modified
reimplantation.
In vitro hydrodynamics, cusp-bending deformation, and root distensibility for
different types of aortic valve–sparing operations: Remodeling, sinus prosthesis,
and reimplantation
Armin Erasmi, MD, Hans-H. Sievers, MD * , Michael Scharfschwerdt, Thorsten
Eckel, Martin Misfeld, MD, PhD
Department of Cardiac Surgery, University Clinic of Schleswig-Holstein, Campus
Luebeck, Luebeck, Germany.

32. Thank you

33. • Reimplantation of the aortic valve in a rigid tube leads toa nonphysiologic movement of the valve leaflets similar
to thatobserved for stented bioprotheses, exposing the leaflets toincreased bending stresses and thus to the risk
of prematurefailure. They maintain that this operation is adequateto avoid secondary dilatation of the aortic root
and still topreserve or restore aortic valve function.
• Remodeling of the aortic root preserves some distensibility,with the propensity to reduce aortic outflow
resistance andthus to lessen the load on the ventricle. It further allowsfor creation of a pseudosinus, allowing
nearly normal openingand closing characteristics of the aortic valve and enhancingits durability [11, 12].David
and Feindel8
have pointed out that, in extensive root dilatation, not onlythe sinuses of Valsalva are dilated but
also the fibrous portionsof the root inferior to the valve insertion line (ie, fibroustrigone and membranous
septum). To correct the root also atthis level, they have proposed mobilization of the root, anchoringa Dacron
graft to the aortoventricular junction, and reimplantationof the aortic valve within the vascular graft.
• Nevertheless, debate still exists about which technique to applyto different pathologic conditions and, more
generally, whatthere is to gain from using valve-sparing techniques comparedwith the standard composite
prostheses. We therefore reviewedour 10-year experience with both types of valve-preserving techniques.

34. • Operative Technique
After median sternotomy, standard cardiopulmonary bypass wasinitiated with a membrane oxygenator (Hollow Fiber Oxygenator,Spiral Gold,
Baxter, Puerto Rico) using antegrade crystalloidor blood cardioplegia. Profound hypothermia (15° to 18°C)was used when circulatory arrest was
necessary. The side ofarterial cannulation was the femoral artery in 32 patients,the right subclavian artery in 5, a combination in 6, and the
ascending aorta in a nondissected area in 121. Venous cannulationwas performed through the right femoral vein in 9 patients andthrough the right
atrium in the rest.
• The operative technique of the remodeling technique (group A)and the reimplantation technique (group B) has been describedin detail [4, 5].
Briefly, the ascending aorta was transected3 mm above the commissures. The sinuses of Valsalva were excised,leaving a 2-mm rim attached to the
crown-shaped annulus. Ifthe dissection affected the aortic root, gelatin-resorcin-formaldehydeglue (GRF; Cardial, Saint E'tienne, France) was used
to readaptthe dissected layers of the aortic wall before the sinuses wereexcised. The size of the tube used was determined by the distancebetween
the straightened commissures giving a macroscopic pictureof appropriate cusps coaptation and the diameter of the baseof the aortic annulus,
measured by means of a Hegar dilator[16].
• According to the adopted procedure, a trimmed or straight HemashildGold tube (Meadox Medicals, Oakland, NY), made with Dacron (DuPont,
Wilmington, DE), was used to replace the excised sinuses. Insome patients, one or more of the sinuses were macroscopicallyintact without any
changes of the underlying pathology; onlyone sinus was replaced in 13 of these patients, and in 5 patientsonly two of the three sinuses were
replaced using the surgicalprinciples of the remodeling technique. In some patients ofthe remodeling group, we used our own technique of
individualreplacement of each sinus with a single piece of Dacron tubeand additional replacement of the ascending aorta.
• In most of the patients, the distal anastomosis was performedin an open fashion using circulatory arrest

35. reimplantation technique caused significantly
higher pressure gradients
Bending deformation indices for all valve-
sparing techniques were more than twice
those of the native aortic root and increased in
relation to the degree the root was fixed with
synthetic noncompliant material.
Aortic root distensibility, expressed as
diastolic-to-systolic change of area, decrea
in all surgical procedures compared with th
of the native aortic root

36. Schematic drawing of measured aortic valve opening and closing characteristics of 3
distinct phases: a-b, rapid valve opening; b-c, slow systolic closure; and c-d, rapid valve
closing movement. RVOT indicates rapid valve opening time; D1, maximal leaflet
displacement; RVCT, rapid valve closing time; ET, ejection time; SCD, slow closing
displacement; and D2, leaflet displacement before rapid valve closing.

37. Diagram of cyclic changes in dimensions
derived from mean values of measured data at
base, sinus, and commissural levels. Note
reduced distensibility in group A at all levels of
aortic root
Opening and Closing Characteristics of the Aortic Valve After Different Types of Valve-Preserving Surgery
Rainer G. Leyh, MD; Claudia Schmidtke, MD; Hans-Hinrich Sievers, PhD, FETCS; Magdi H. Yacoub, PhD, FRCS
From the Departments of Cardiac Surgery, Medical University of Lübeck, Lübeck, Germany (R.G.L., C.S., H.-
H.S.), and the National Heart and Lung Institute at the Imperial College of Science, Technology, and Medicine,
London, UK (M.H.Y.).

38. EVOA is constant in both compliant and stiff
roots
Aortic valve regional
stresses in the normal aortic
root and clinical valve-
sparing models. *P = .0001
and {dagger}P = .0005
indicate significant
difference as compared with
the normal root model. b,
Schematics of altered leaflet
stress patterns in the graft
models as compared with
normal.
RE-CREATION OF SINUSES IS IMPORTANT FOR SPARING THE
AORTIC VALVE: A FINITE ELEMENT STUDY
K. Jane Grande-Allen, PhDa, Richard P. Cochran, MDb, Per G.
Reinhall, PhDc, Karyn S. Kunzelman, PhDb
From the Department of Biomedical Engineering, Cleveland Clinic
Foundation, Cleveland, Ohioa; Division of Cardiothoracic Surgery,
University of Wisconsin, Madison, Wisb; and Department of
Mechanical Engineering, University of Washington, Seattle, Wash.c

39. Both techniques are widely used in the case of aortic root aneurysms associated
with non-diseased aortic valves.
The classic remodeling technique allows a good anatomical reconstruction of
the sinuses of Valsalva but has a higher incidence of residual valve
regurgitation.
the classic reimplantation technique permits more stable results through
annulus stabilization but completely abolishes the sinuses of Valsalva

40. Adapting the Valsalva graft to the patient's
anatomy (I). When the height of the
commissures matches the height of the ‘skirt’
the collar is cut out and the lower row of
sutures are passed at the base of the skirt. In
this way the top of the commissures will reach
the level of the new sino-tubular junction (the
connection between the two sections of
Dacron)
Adapting the Valsalva graft to the patient's
anatomy (II). When the height of the
commissures is shorter than the height of the
‘skirt’ the collar is cut out and the lower row of
sutures are passed at the corresponding level
inside the skirt. The top of the commissures
will therefore be at the level of the new sino-
tubular junction.

41. Adapting the Valsalva graft to the patient's anatomy (III). In the
rare cases when the height of the commissures is longer than the
height of the ‘skirt’ the collar can be utilized to secure the lower
row of sutures, to increase the length of the reconstructed root
and to consent that the top of the commissures reaches the level
of the new sino-tubular junction.

42. Because of its particular shape, the use of the Valsalva graft simplifies
the surgical procedure by offering:
•Decreased tension during coronary artery suturing
•Decreased tension after graft pressurization
•Increased anatomical adaptability
•Decreased potential for suture bleeding and pseudoaneurysm
formation
•Easier access to the coronary anastomosis at the end of procedure

45. Remodeling of the aortic root combined to an
expansible aortic ring annuloplasty

46. Standardized and physiological approach to
aortic valve repair according to each
phenotype of ascending aorta. (Reproduced
from Ref. [17] with permission from Elsevier.)

47. Remodeling of the aortic root
associated to an external
subvalvular aortic annuloplasty
(CAVIAAR technique),
combining advantages of the
original remodeling and
reimplantation techniques:
‘remodeling’ technique
provides the most
physiological reconstruction of
the root, but it does not
address the dilated annular
base. Alternatively, the
reimplantation, as an inclusion
technique, provides a
subvalvular annuloplasty to
the detriment of valve
dynamics [6, 7,
9,10,11,12,13,14,15,16].
(Reproduced from Ref. [17]
with permission from Elsevier.)

48. Criteria for the choice of the subvalvular aortic
ring and Valsalva graft.

49. First step of valve repair: alignment of
adjacent cusp free edges
Placement of the subvalvular expansible aortic
ring (A) and final aspect of the aortic root (B).
(Reproduced from Ref. [17] with permission
from Elsevier.)
Placement of the five anchoring
subvalvular ‘U’ stitches

50. Aortic root aneurysm for bicuspid valves: remodeling of the
aortic root, resuspension of cusp effective height and
subvalvular aortic annuloplasty.

51. • One hundred and eighty-seven patients underwent remodeling associated with a subvalvular
aortic ring annuloplasty (14 centers, 24 surgeons). Three strategies for cusp repair were evaluated:
Group 1: gross visual estimation (74 patients), Group 2: alignment of cusp free edges (62 patients),
Group 3: two-steps approach associating alignment of cusp free edges with effective height
resuspension (51 patients). A composite outcome was defined as recurrence of aortic insufficiency
grade 2 and/or reoperation. Operative mortality was 3.2% (20). Treatment of cusp lesion was≧
most frequently performed in Group 3 (70.6%, vs. 20.3% Group 1 and 30.6% Group 2, P 0.001).≪
Nine patients required reoperation during follow-up [24 months (12–45)], from Group 1 (6) and
Group 2 (3). At one year, no patients in Group 3 presented with composite outcome events (vs.
28.1% Group 1, 15% Group 2, P 0.001). Residual aortic insufficiency and tricuspid anatomy were≪
independent risk factors for composite outcome in Groups 1 and 2. Annulus diameter, Marfan
syndrome and cusp repair had no effect on aortic insufficiency recurrence or reoperation [

52. Conclusions: In vitro the various aortic valve–
sparing operations differed charac- teristically
in their ability to spare valve function, none of
them completely meeting native valve
behavior. The remodeling techniques
exhibited valve dynamics closest to those of
the native aortic root. The more the aortic
valve is fixed with noncom- pliant prosthetic
material, the more the native root dynamics
are impaired.