The introduction of the Y(ang)-technique for aortic root enlargement has sparked a renewed interest in annular and root enlargement procedures world-wide. In order to execute these procedures proficiently however, it's important to understand the complex three-dimensional structure of the aortic root and left ventricular outflow tract, and also be familiar with the different enlargement techniques. Herein, we are providing a description of the aortic root anatomy and the most commonly utilized root enlargement procedures. This should facilitate clinical decision making and guidance of patients towards the most appropriate procedure, which should not only treat the patients' acute symptoms, but should also set the patient up for potentially needed future procedures and respective life-time management of aortic valve disease.

Unicuspid aortic valves are rare congenital malformations. Surgical repair is feasible in aortic regurgitation, and in some cases of aortic stenosis. The standard surgical approach is a bicuspidization and symmetrization with pericardial patch augmentation of valve leaflets. Herein, we are describing our original technique for bicuspidization of a unicuspid aortic valve in adults without leaflet patch augmentation. We also address the surgical management of a commissural diastasis.

Aortic valve and root replacements require an in-depth understanding of the aortic root and annulus. Both structures can be asymmetric at times, and this needs to be recognized and taken into consideration when performing valve-sparing operations or other root-replacement procedures. Moreover, the geometry of the aortic annulus can be altered, and when performing an aortic root replacement this can distort the geometry of a neoaortic valve for instance, and lead to valve dysfunction, which is difficult to reverse. We are describing an altered aortic annulus, which required modification through annulus elevation before proceeding with aortic root replacement with a graft-reinforced pulmonary-autograft.

The authors reported no conflicts of interest.The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. The pursuit of the best valve-sparing treatment strategy for aortic root disease in patients with Marfan syndrome has been the subject of intense debate over the past few decades. Two surgical approaches are commonly employed and are known as the remodeling (ie, Yacoub) or reimplantation (ie, David) technique.1Sarsam M.A. Yacoub M. Remodeling of the aortic valve anulus.J Thorac Cardiovasc Surg. 1993; 105: 435-438Google Scholar,2David T.E. Feindel C.M. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta.J Thorac Cardiovasc Surg. 1992; 103: 617-621Google Scholar During the mid-1990s, the topic was center stage at the American Association for Thoracic Surgery and other prominent surgical meetings. Sir Magdi Yacoub and Tirone David were advocating for their respective techniques, and each had contemporary proponents, which is the case to this day. Urbanski and colleagues3Urbanski P.P. Jankulowski A. Morka A. Irimie V. Zhan X. Zacher M. et al.Patient-tailored aortic root repair in adult marfanoid patients: surgical considerations and outcomes.J Thorac Cardiovasc Surg. 2018; 155: 43-51.e41Google Scholar recently demonstrated their results with a modified remodeling technique in patients with Marfan syndrome and concluded that it is an effective and durable method. However, mean follow-up of their cohort was just 6.1 ± 3.1 years, ranging from 0.8 to 14.2 years, and reaching a verdict this early may just have been a little premature. We are now beginning to gain new insights because patients with 20 years of follow-up after undergoing Yacoub or David procedure are returning to our clinics (Figure 1). Our concern has been that although both procedures adequately address the acute pathology, long-term successful outcomes are limited by recurrence of aortic annular enlargement, or more importantly, aortic root dilation in patients who have undergone the remodeling technique. Although clinicians have neglected to consider recurrent aortic root enlargement as a possibility, this is exactly what we are witnessing today. Urbanski and colleagues3Urbanski P.P. Jankulowski A. Morka A. Irimie V. Zhan X. Zacher M. et al.Patient-tailored aortic root repair in adult marfanoid patients: surgical considerations and outcomes.J Thorac Cardiovasc Surg. 2018; 155: 43-51.e41Google Scholar state that recurrent dilatation of the neosinuses occurs due to unstable suture lines, and that a more precise suturing to the annulus, rather than the aortic wall remnant, would provide lasting durability and aid with hemostasis. This sentiment is derived from the early days, when Sir Magdi Yacoub advocated for this approach to achieve a durable annuloplasty effect (Video 1) as he referred to the ringlike junction of the aortic wall and ventricle as the surgical annulus.1Sarsam M.A. Yacoub M. Remodeling of the aortic valve anulus.J Thorac Cardiovasc Surg. 1993; 105: 435-438Google Scholar Schneider and colleagues4Schneider U. Ehrlich T. Karliova I. Giebels C. Schafers H.J. Valve-sparing aortic root replacement in patients with Marfan syndrome-the Homburg experience.Ann Cardiothorac Surg. 2017; 6: 697-703Google Scholar as well as Lansac and colleagues5Lansac E. Di Centa I. Varnous S. Rama A. Jault F. Duran C.M. et al.External aortic annuloplasty ring for valve-sparing procedures.Ann Thorac Surg. 2005; 79: 356-358Google Scholar have hypothesized that the better long-term results seen with the reimplantation technique are likely due to better annular stabilization and have henceforth added an annuloplasty to their remodeling technique to obviate the future annular dilatation in Marfan patients. This stems from a better understanding of the functional aortic annulus and the need for a more durable annular stabilization at the level of the virtual basal ring. Thus, proponents of the remodeling technique have understood that a meticulous suturing technique alone, closer to the hinge point of the valve leaflets—the surgical annulus—may not suffice. Annular dilatation is certainly a concern but it isn't the only area of interest. We now know that recurrent aortic root enlargement in Marfan patients can occur in the absence of aortic annular enlargement, and despite a meticulous suturing technique. The dilation can occur in any unsupported area, such as the interleaflet/subcommissural triangles, as well as any remaining aortic root tissues left behind. Moreover, even the suture line between the graft and the valve insertion is at risk (Figure E1). The reimplantation technique not only provides an effective annuloplasty, but it also functionally excludes all the tissues at risk for dilation through inclusion within the prosthetic graft and thereby eliminating possible recurrent aortic root dilatation later. Twenty years after aortic root replacement for aortic root aneurysm in a Marfan patient with the reimplantation technique, we are seeing a stable annulus and stable aortic root, without any aortic root dilatation (Figure 1). In contrast, despite our meticulous suturing technique (Video 1), after a valve-sparing remodeling procedure 20 years ago, we encountered a severe aortic root enlargement (Figure 1). This occurred in the presence of aortic annular enlargement (3.2 cm) but the indication for surgery was driven by the severe aortic root enlargement (6.2 cm), and hence required a redo valve-sparing reimplantation technique. The substrate for the recurrent severe aortic root dilatation was the combination of chronic suture line dehiscence as well as enlargement of any remaining aortic tissues between the valve insertion and the suture line (Figure E2, A and B). We are just now starting to see the 20-year results after initial valve-sparing aortic root replacement in Marfan patients. And what we observe is recurrent severe aortic root enlargement after the remodeling technique, and stable repair after the reimplantation technique. Figure E2A, Remodeling technique in patients with Marfan syndrome. The red area depicts the area at high risk for dilation or dehiscence. Orange area depicts annular and subcommissural area at risk for dilatation. A∗, Magnification of commissures depicting the correct suturing technique at the valve insertion. B, Remodeling technique and annuloplasty in Marfan syndrome. Colored area indicates area at risk for dehiscence and dilatation. C, Reimplantation technique in patients with Marfan syndrome.View Large Image Figure ViewerDownload Hi-res image Download (PPT) https://www.jtcvsopen.org/cms/asset/35fbb1b3-5523-49b9-b6b2-84a6d9a666b1/mmc1.mp4Loading ... Download .mp4 (40.63 MB) Help with .mp4 files Video 1Our remodeling (Yacoub) technique over the past 3 decades. The video describes our suture technique for the prosthetic graft to the aortic remnant during the remodeling technique. Video available at: https://www.jtcvs.org/article/S2666-2736(21)00199-6/fulltext. Patient-tailored aortic root repair in adult marfanoid patients: Surgical considerations and outcomesThe Journal of Thoracic and Cardiovascular SurgeryVol. 155Issue 1PreviewThe aim of the study was to evaluate the operative and functional results after individual, patient-tailored aortic root repair in marfanoid patients. Full-Text PDF Open ArchiveReply: For connective disease root aneurysms, reimplantation is the best optionJTCVS OpenVol. 7PreviewJahanyar and colleagues1 conclude that upon late follow-up, the remodeling operation is prone to fail in patients with Marfan syndrome, but the reimplantation operation holds up better. We agree and came to the same conclusion a number of years ago2; as a result, we stopped using the remodeling operation for Marfan patients, except for bicuspid valve patients with large roots (a rare occurrence). Similar to what the authors describe, we saw either failures from dilation at the annular suture or in the intercommissure angle. Full-Text PDF Open Access

We present the case of a twenty-eight-year-old male with severe aortic stenosis and mean gradient across the aortic valve (AV) of 52 mmHg, due to a calcified congenital unicuspid AV. The patient was asymptomatic, without significant past medical history, and clean coronaries. Due to extensive AV calcifications, AV repair was not feasible, and Ross procedure was indicated. Echocardiography identified a dilated aortic annulus of 28 mm; the aortic root and ascending aorta were 34 and 40 mm in diameter, respectively. Following our treatment strategy for Ross procedure, Dacron-graft inclusion was the preferred technique because of young age and the dilated aortic annulus and ascending aorta.

Right-sided infective endocarditis (IE) accounts for 5% to 10% of all endocarditis cases. In this setting, the tricuspid valve is the most commonly affected valve, and intravenous drug abuse is the leading cause for right-sided IE.1