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EDITORIAL |
France
Full root aortic replacement with a stentless tissue valve has been introduced over the past 15 years. At the start, this operation was considered complex surgery to be performed only by highly experienced surgeons used to homograft surgery. Today, various reasons lead us to revisit the role of the stentless valve in aortic surgery. The technique of full root replacement is now well standardized. After accurate sizing, a continuous running suture allows subannular implantation of the valve, without any technical problem, even in the case of an altered annulus (such as in redo surgery or highly calcified aortic stenosis). Implantation of the aortic buttons carrying the coronary ostia can be performed safely using Teflon or pericardial strips, or a double-layer suture technique (personal technique). Generally, the procedure can be performed reproducibly within 60–80 min, far within the safety period of myocardial ischemia using present cardioplegia techniques.1 It can be concluded that there is no technical concern related to the use of stentless valves. Training of inexperienced cardiac surgeons can be easily achieved since the technique is now clearly standardized.
The advantages of stentless valve replacements are mainly due to the mechanical and hemodynamic performance of the valve. Stress-related structural changes in the valvular tissue are minimized, and this should permit prolonged valve durability.2 The low gradients observed in both the postoperative period and the long term should enhance the extent of left ventricular remodeling. The superior valve performance characteristics are obvious, especially with the small-sized valves, compared to subcoronary and stented valve implantations.3 Three other reasons support the wider use of stentless valves. First, avoidance of anticoagulation which is a risk in the elderly especially and a nightmare for people living in remote areas. Second, there is more pronounced normalization of coronary blood flow after stentless valve replacement compared to using stented valves, and improved left ventricular recovery and patient performance during exercise can be expected.4 Third, the recent publication of 10-year results with the stentless valve should give potential users increased confidence in this approach; freedom from reoperation was extremely high (98%) at 9 years.5 In addition, ongoing studies by our group, looking at morphological changes and calcification of the aortic wall using magnetic resonance imaging, do not show any reason to worry about structural changes in the aortic wall with a stentless valve. These characteristics should lead us to revisit the indications for stentless valves in various categories of patients.
In young adults, the incidence of a bicuspid valve is high (30%–50%), so full root replacement is probably the best option. The incidence of dilatation of the sinus following valve replacement is probably underestimated, as is the risk of aortic dissection at the level of the Valsalva sinuses after stented valve replacement. The sinus of Valsalva tissue structure is abnormal even if the sinus is not dilated at the time of valve replacement. These observations mean that radical aortic root treatment is preferred rather than valve replacement only. The bicuspid valve itself does not incur any particular technical issue. In young females, this approach allows patients to become pregnant without any problem. Aside from the prolonged durability of the stentless valve, the issue of reoperation should not deny a patient the benefits of this valve. Surgical redo does not appear to present any special technical problem because separation of the aortic wall from the surrounding tissue is facilitated by the lack of firm adhesions. In addition, with the rapid development of a transcatheter valve, the possibility of nonsurgical valve replacement may be expected within 5–10 years. In the 50–65-year age group, the above-mentioned advantages of stentless valve aortic root replacement will help to reduce the anticoagulant-related risks of mechanical valves. In redo cases, as in patients with endocarditis, poor quality of the aortic annulus does not compromise the ease of implantation of a stentless valve. The soft sewing ring of the stentless valve will reduce technical problems during surgery and minimize the risk of perivalvular leakage postoperatively. Finally, in the elderly population with highly calcified valves and often a small valvular annulus, full root replacement dramatically facilitates the surgery. The presence of calcification on the walls of the Valsalva sinuses is no longer an issue after excision because the coronary ostia are usually preserved and the proposed reimplantation technique is quite safe. The superior hemodynamic performance is obvious when compared with stented or subcoronary stentless valve implantations.
On the whole, fears of using stentless aortic valves in a full root replacement technique are not justified, and the advantages of this innovative approach should be offered more frequently to a wider group of patients by a growing number of surgeons.
REFERENCES
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