Aortic valve sparing techniques: pearls and pitfalls

Aortic valve sparing procedures became more popular in the last decades due to the better understanding of aortic root physiology. Searching for an optimal root reconstruction several modifications have been proposed to the original reimplantation (David) and to the remodeling (Yacoub) technique. Currently, the most adopted technique worldwide is the reimplantation because of its peculiar characteristics of annular stabilization, support of the aortic wall, and better hemostatic efficacy. The remodeling technique aims for optimal root restoration, but does not prevent annular dilatation and may be associated with a higher risk of bleeding. The main theoretical issue with the classic reimplantation operation is the elimination of Valsalva’s sinuses which play a fundamental role in regulating leaflet dynamics. On the other hand, data on long-term aortic valve performance in classic reimplantation procedures without sinuses appears to hold well the test of time. However, over the time this technique has been often modified attempting to re-create sinuses, it is therefore difficult to draw definite conclusions. In the last decade, the use of “anatomic” Dacron graft designed specifically for root reconstruction or specific modifications to the straight Dacron graft, led to a standardization of the technique and consequently to a stable improvement of the results and to the diffusion of the reimplantation. However, long-term durability of the spared valve assessed by the incidence of residual aortic valve insufficiency and/or the need for reoperation during the follow-up is still to be clarified. Overall, the results are satisfactory especially in consideration of the relatively “young age” of this technique. A spared aortic valve with moderate valve regurgitation and/or eccentric aortic jet soon after the procedure, will invariably lead to a later need for reoperation. Therefore, a good coaptation height inside a repaired root warrant long-lasting results.