Valve sparing root replacement with the reimplantation technique in patients presenting with acute type A aortic dissections

Patients presenting with acute type A aortic dissections (ATAAD) comprise an extremely heterogenous population. While a majority are older and suffer from chronic disease states, a non-insignificant minority are relatively healthy without long standing aneurysmal or aortic valve pathology. Selection of an appropriate proximal and distal operation can affect short- and long-term morbidity and mortality as well as the need for valve reintervention. In regard to management of the root, surgeons must be aggressive when indications for replacement—such as a sinus tear, aneurysmal degeneration, or friable tissue—are evident. In experienced centers, it is reasonable to proceed with a valve-sparing procedure in well selected patients. The risks and benefits of this decision must be considered carefully as a root replacement with either a biologic or mechanical prosthesis is preferred over a poorly executed valve sparing procedure. However, if the latter is approached in a standardized fashion with attention to the patient’s overall acuity, cardiac function, and aortic valve leaflet mobility, reproducible outcomes can and should be expected. Accordingly, we present our approach to valve sparing root replacement with the reimplantation technique in ATAAD. The following review includes a case-based discussion and video depiction of our technique, including safe and reliable cannulation methods for bypass, cerebral protection strategies, and a structured approach to critically appraise the valve prior to repair.